chapter 33 face and neck trauma. national ems education standard competencies trauma integrates...

Chapter 33Chapter 33

Face and Neck Trauma

National EMS Education Standard CompetenciesNational EMS Education Standard Competencies

Trauma

Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient.


Head, Facial, Neck, and Spine Trauma

Recognition and management of

• Life threats

• Spine trauma



Pathophysiology, assessment, and management of− Penetrating neck trauma

− Laryngotracheal injuries

− Spine trauma• Dislocations/subluxations

• Fractures

• Sprains/strains



Pathophysiology, assessment, and management of− Facial fractures

− Skull fractures

− Foreign bodies in the eyes

− Dental trauma



Pathophysiology, assessment, and management of− Unstable facial fractures

− Orbital fractures

− Perforated tympanic membrane

− Mandibular fractures

IntroductionIntroduction

• You will commonly encounter patients with injuries to the face and neck. − These injuries can be some of the most graphic

you will see.

The Facial BonesThe Facial Bones

• 14 facial bones− Protect the eyes,

nose, and tongue

− Provide attachment points for the muscles that allow chewing


• Two major nerves provide control: − Trigeminal nerve

• Ophthalmic nerve

• Maxillary nerve

• Mandibular nerve

− Facial nerve


• Orbits− Cone-shaped fossae

− Enclose and protect the eyes


• Nose− Nasal septum

separates the nostrils

− External portion is formed of cartilage

− Paranasal sinuses• Hollowed bone

lined with membranes


• Mandible− Movable bone forming the lower jaw

• Temporomandibular joint (TMJ) − Allows movement of the mandible

The EyeThe Eye

• Globe: spherical structure housed within the orbit

• Oculomotor nerve − Innervates the

muscles that cause motion

• Optic nerve− Provides the sense

of vision

The EyeThe Eye

• Structures of the eye include:− Sclera

− Cornea

− Conjunctiva

− Iris

− Pupil

− Lens

− Retina

The EyeThe Eye

The EyeThe Eye

• Anterior chamber is filled with aqueous humor. − If lost, it will be

replenished.

• Posterior chamber is filled with vitreous humor.− If lost, it cannot be

replenished.

The EyeThe Eye

• Two types of vision: − Central vision

• Visualization of objects directly in front of you

− Peripheral vision • Visualization of lateral objects

The EarThe Ear

• Divided into three anatomic parts− External ear

− Middle ear

− Inner ear

The EarThe Ear

The EarThe Ear

• Sound waves enter through the pinna.− Travel to the tympanic membrane

− Vibration is transmitted to the cochlear duct.

− At the organ of Corti, vibration forms nerve impulses that travel to the brain.

The TeethThe Teeth

• 32 permanent teeth − Distributed about

the maxillary and mandibular arches

− Four quadrants

The TeethThe Teeth

• Crown: top portion of the tooth

• Pulp cavity fills the center of the tooth and contains: − Blood vessels

− Nerves

− Specialized connective tissue

The MouthThe Mouth

• Digestion begins with mastication.

• Tongue: primary organ of taste

The MouthThe Mouth

• Hypoglossal nerve− Provides motor

function to tongue

• Glossopharyngeal nerve − Provides taste

sensation

• Mandibular branch of trigeminal nerve− Provides motor

innervation

• Facial nerve− Provides taste and

sensations

The Anterior Region of the Neck


• Structures:− Thyroid and cricoid

cartilage

− Trachea

− Muscles and nerves



• Major blood vessels: − Carotid arteries

− Jugular veins

Scene Size-UpScene Size-Up

• Assess and address any hazards.

• Determine the number of patients.

• Consider need for additional resources.

• Evaluate the mechanism of injury (MOI).

Primary AssessmentPrimary Assessment

• Form a general impression.− Determine whether life threats are present.

− If potential for neck or spine injury exists, perform manual immobilization.

− Check for responsiveness.


• Airway and breathing− Determine whether air is moving.

− Suction as needed.

− Correct airway patency.

− Assess the patient’s breathing.


• Circulation− Palpate the pulse.

− Inspect the skin.

− Control significant bleeding.

− If multiple systems are likely affected, perform a rapid exam.


• Transport decision− The following require immediate transport:

• Poor initial general impression

• Altered level of consciousness

• Dyspnea

• Abnormal vital signs

• Shock

• Severe pain


• Transport decision (cont’d)− Other signs that require rapid transport:

• Tachycardia

• Tachypnea

• Weak pulse

• Cool, moist, and pale skin

History TakingHistory Taking

• Was there a precipitating factor?

• Ask about the injury.− Record information on the patient care record.

• If unresponsive, your only sources of information may be:− The scene

− Medic Alert jewelry

Secondary AssessmentSecondary Assessment

• Assess the respiratory system. − Listen for air movement and breath sounds.

− Determine the rate and quality of respiration.

− Assess for asymmetric chest wall movement.


• Assess the neurologic system.− Level of consciousness

− Pupil size and reactivity

− Motor response

− Sensory response


• Assess the musculoskeletal system. − Look for DCAP-BTLS.

− Assess the chest, abdomen, and extremities.

− Assess the posterior torso.


• Assess all anatomic regions.

• Record pulse, motor, and sensory function.

• Reassess the vital signs.

ReassessmentReassessment

• Obtain and evaluate vital signs.

• Check interventions.

• Repeat the primary assessment.

ReassessmentReassessment

• Documentation should include:− Description of the MOI

− Position in which you found the patient

− Location and description of injuries

− Accurate account of treatment

Emergency Medical CareEmergency Medical Care

• Focus on airway protection.

• Expose wounds, control bleeding, and prepare to treat for shock.− Patients with major closed soft-tissue injury

should receive oxygen.

− Splint painful, swollen, or deformed extremities.

Pathophysiology of Face Injuries


• Soft-tissue injuries− Open injuries can

indicate more severe injuries.

− Maintain a high index of suspicion with closed soft-tissue injuries.

Courtesy of Rhonda Beck



• Soft-tissue injuries (cont’d)− Impaled objects present risk of airway

compromise.

− Massive oropharyngeal bleeding can result in: • Airway obstruction

• Aspiration

• Ventilator inadequacy



• Maxillofacial fractures− Occur when facial bones absorb strong impact

− When assessing, protect the cervical spine.

− First clue: ecchymosis



• Nasal fractures − Nasal bones are not structurally sound.

− Characterized by: • Swelling

• Tenderness

• Crepitus



• Mandibular fractures and dislocations− Suspect in patients with blunt force trauma to

lower third of face, presenting with: • Dental malocclusion

• Numbness of the chin

• Inability to open the mouth



• Maxillary fractures − Produce:

• Massive facial swelling

• Instability of the midfacial bones

• Malocclusion

• Elongated appearance of the face



• Maxillary fractures (cont’d)− Le Fort fractures are classified into:

• Le Fort I fracture

• Le Fort II fracture

• Le Fort III fracture



• Orbital fractures − Signs and symptoms include:

• Infraorbital hypoesthesia

• Enophthalmos traumaticus

• Massive nasal discharge

• Impaired vision

• Paralysis of upward gaze



• Zygomatic fractures − Signs and symptoms include:

• Flattened appearance on face

• Loss of sensation over cheek, nose, and upper lip

• Paralysis of upward gaze

Assessment of Face InjuriesAssessment of Face Injuries

• It is not important to distinguish among the various fractures in the prehospital setting.

• Assessment is primarily clinical.

• Pay attention to:− Swelling and deformity

− Instability

− Blood loss

Assessment of Face InjuriesAssessment of Face Injuries

• Evaluate the cranial nerve function.

• Visually inspect the oropharynx for signs of posterior epistaxis. − Alert the ED to this situation.

Management of Face InjuriesManagement of Face Injuries

• Protect the cervical spine.

• Inspect the mouth for objects that could obstruct the airway.

• Suction the oropharynx as needed.

• Insert an airway adjunct as needed.


• Assess breathing and intervene appropriately.

• Perform ET intubation.− Cricothyrotomy

may be required.© Eddie M. Sperling


• Soft-tissue injuries− Control bleeding with direct pressure; apply

sterile dressings.

− Leave impaled objects in the face unless they pose a threat to the airway


• Soft-tissue injuries (cont’d)− For severe oropharyngeal bleeding with

inadequate ventilation:• Suction the airway for 15 seconds.

• Provide ventilatory assistance for 2 minutes.

• Continue alternating until the airway is cleared or secured.


• Soft-tissue injuries (cont’d)− Epistaxis is most effectively controlled by

applying direct pressure to the nares.• Responsive patients should sit up and forward.

• Unresponsive patients should be positioned on their side.


• Maxillofacial fractures− Cold compresses may reduce swelling, pain

− Determine:• Whether patient has significant medical problems

• Approximate time of injury

• Any drug allergies and last oral intake

Pathophysiology of Eye Injuries


• Lacerations− Compression to the globe can:

• Interfere with blood supply

• Squeeze the vitreous humor, iris, lens, or retina out of the eye



• Foreign bodies, impaled objects− Foreign objects

can produce irritation. • Conjunctivitis:

inflamed and red conjunctiva

• Eye produces tears.



• Blunt eye injuries− Hyphema: bleeding into anterior chamber that

obscures vision



• Blunt eye injuries (cont’d)− Orbital blowout

fractures• Fragments of bone

can entrap eye muscles

− Retinal detachment: separation of retina from choroid



• Burns of the eye− Chemical burns require immediate emergency

care.• Flush with water or a sterile saline solution.



• Burns of the eye (cont’d)− Thermal burns occur when a patient is burned

in the face during a fire.



• Burns of the eye (cont’d)− Infrared rays, eclipse light, and laser burns can

damage sensory cells.

− Superficial burns can result from ultraviolet rays. • May not be painful initially

Assessment of Eye InjuriesAssessment of Eye Injuries

• Note the MOI.

• Ensure a patent airway.

• Control any external bleeding.

• If appropriate, perform a rapid exam.


• When obtaining the history, determine: − How and when did the injury happen?

− When did the symptoms begin?

− What symptoms is the patient experiencing?

− Were both eyes affected?

− Are there underlying diseases or conditions?

− Does the patient take medications?


• Symptoms of serious ocular injury:− Visual loss

− Double vision

− Severe eye pain

− A foreign body sensation


• During physical examination, evaluate:− Orbital rim: ecchymosis, swelling, lacerations,

tenderness

− Eyelids: ecchymosis, swelling, lacerations

− Corneas: foreign bodies

− Conjunctivae: redness, pus, inflammation, foreign bodies


• During physical examination, evaluate (cont’d):− Globes: redness, abnormal pigmentation,

lacerations

− Pupils: size, shape, equality, reaction to light

− Eye movements: paralysis of gaze or discoordination between eyes

− Visual acuity: ask patient to read a newspaper

Management of Eye InjuriesManagement of Eye Injuries

• Lacerations and blunt trauma− Prehospital care of injuries to the eyelids:

• Bleeding control

• Gentle patching of the eye

− Most globe injuries are best treated in the ED.


• Lacerations and blunt trauma (cont’d)− When treating penetrating injuries of the eye:

• Never exert pressure on the injured globe.

• If part of the globe is exposed, gently apply a moist, sterile dressing.

• Cover with a protective shield, cup, or dressing.

• Apply soft dressings; provide transport.


• Lacerations and blunt trauma (cont’d)− If hyphema or rupture of

the globe is suspected, take spinal motion restriction precautions.

− If the globe is displaced out of its socket, do not attempt to manipulate or reposition it.

Courtesy of AAOS


• Foreign bodies, impaled objects− Do not remove a

foreign body impaled in the globe.

− Stabilize object.

− Promptly transport the patient.


• Burns caused by ultraviolet light− Cover with a sterile, moist pad and eye shield.

− Apply cool compresses if patient is in distress.

− Place the patient in a supine position.


• Chemical burns− Immediately irrigate with water or saline

solution.

− Avoid contaminated water getting into unaffected eye.

− Irrigate for at least 5 minutes.


Courtesy of AAOS Courtesy of AAOS

Courtesy of AAOS Courtesy of AAOS


• To examine the undersurface of the upper eyelid, pull the lid upward and forward. − If you spot a foreign object, remove it with a

moist, sterile, cotton-tipped applicator. • Unless imbedded in the cornea

Pathophysiology of Ear Injuries


• Soft-tissue injuries− Pinna has a poor blood supply.

• Tends to heal poorly

• Healing is often complicated by infection.



• Ruptured eardrum− Signs and symptoms include:

• Loss of hearing

• Blood drainage from the ear

− Typically heals spontaneously

Assessment and Management of Ear Injuries


• Ensure breathing adequacy.

• If MOI suggests spinal injury, apply full spinal motion restriction precautions.



• If direct pressure does not control bleeding: − Place dressing between ear and scalp.

− Apply roller bandage.

− Apply ice pack.



• If partially avulsed: − Realign the ear

into position.

− Gently bandage with padding that has been slightly moistened with normal saline.

• If completely avulsed: − Wrap it in saline-

moistened gauze.

− Place in plastic bag and place bag on ice.



• If blood or CSF drainage is noted: − Apply a loose dressing over the ear.

− Assess for basilar skull fracture.

• Do not remove an impaled object. − Stabilize the object.

− Cover the ear to prevent movement and minimize contamination.

Pathophysiology of Oral and Dental Injuries


• Soft-tissue injuries− Place the

responsive patient with severe oral bleeding leaning forward.

− Impaled objects can result in profuse bleeding.

© E. M. Singletary, MD. Used with permission



• Dental injuries− May be associated with mechanisms that cause

severe maxillofacial trauma

− Always assess the mouth following facial injury.

Assessment and Management of Oral and Dental Injuries


• Ensure adequate breathing. − Suction the oropharynx as needed.

− Remove fractured tooth fragments.

− Apply spinal motion restriction precautions as dictated by the MOI.



• Impaled objects should be stabilized. − Unless they interfere with airway

• To replant an avulsed tooth:− Place the tooth in its socket.

− Hold it in place with or have patient bite down.

Pathophysiology of Injuries to the Anterior Part of the Neck


• Soft-tissue injuries− Blunt trauma often results in:

• Swelling and edema

• Injury to the various structures

• Injury to the cervical spine

− Be prepared to initiate aggressive management.



• Soft-tissue injuries (cont’d)− Primary threats from penetrating trauma:

• Massive hemorrhage

• Airway compromise

− Air embolisms are associated with open neck injuries.



• Soft-tissue injuries (cont’d)− Impaled objects

can present life-threatening problems. • Do not remove

impaled objects unless they interfere with the airway.



• Injuries to larynx, trachea, and esophagus− Can be easily overlooked

− Significant injuries to the larynx and trachea pose risk of airway compromise.

− Esophageal perforation can result in mediastinitis.

Assessment of Injuries to the Anterior Part of the Neck


• Common signs:− Bruising

− Redness to the overlying skin

− Palpable tenderness

• Note MOI; maintain high index of suspicion



• If patient is unresponsive: − Stabilize head in a neutral in-line position.

− Open airway with the jaw-thrust maneuver.

• Assess the patient’s breathing.

Management of Injuries to the Anterior Part of the Neck


• To control bleeding from an open neck wound, cover with an occlusive dressing. − Apply direct

pressure with a bulky dressing.

− Secure by wrapping roller gauze loosely.



• Monitor for reflex bradycardia.

• Advise the patient to refrain from speaking.

• If signs of shock are present: − Keep the patient warm.

− Establish vascular access.

− Infuse an isotonic crystalloid solution.



• Patients may require a surgical or percutaneous airway.− Use multiple techniques for confirming correct

ET tube placement.

Pathophysiology of Spine Trauma

Pathophysiology of Spine Trauma

• Sprain: stretching or tearing of ligaments− Provide cervical spine stabilization.

• Strain: stretching or tearing of muscle or tendon− Cervical precautions should be taken.

Assessment of Spine TraumaAssessment of Spine Trauma

• Transport to the ED for radiologic studies.

• Conduct a visual inspection.

• If the patient is symptomatic with pain, maintain spinal stabilization.

Assessment of Spine TraumaAssessment of Spine Trauma

• If MOI dictates spinal clearance protocol and examination produces pain:− Stop the examination.

− Maintain spinal stabilization.

− Transport for further evaluation in the ED.

Management of Spine TraumaManagement of Spine Trauma

• Patients reporting neck pain after injury should be evaluated in the ED.

• Address airway, ventilation, and oxygenation considerations.

• Prevent further injury with motion restrictions.

Management of Spine TraumaManagement of Spine Trauma

• If your examination reveals no obvious MOI, consider treatment for muscular strain. − Rest, ice, elevation

− Soft collar

Injury PreventionInjury Prevention

• Prevention during activities in which the risk of being hit is high:− Helmets

− Face shields

− Mouth guards

− Safety glasses

Injury PreventionInjury Prevention

• Advances in motor vehicle safety include: − Better occupant safety restraints and air bags

− Improvements to the headrests

SummarySummary

• A strong knowledge of anatomy and physiology of the face, head, and brain is essential to accurately assess and manage patients with injuries to these locations.

• Personal safety is your initial primary concern when you are treating any patient with head or face trauma.

• Head and face trauma most often result from direct trauma or rapid deceleration.

SummarySummary

• Trauma to the face can range from a broken nose to more severe injuries.

• Your primary concerns with assessing and managing a patient with facial trauma are to ensure a patent airway and maintain adequate oxygenation and ventilation.

• Any patient with head or face trauma should be suspected of having a spinal injury.

SummarySummary

• Blind nasotracheal intubation is relatively contraindicated in the presence of midface fracture.

• Remove impaled objects in the face or throat only if they impair breathing or if they interfere with your ability to manage the airway.

• Injuries to the eye can be varied, including lacerations, blunt trauma, impaled objects, or burns.

SummarySummary

• Never remove impaled objects from the eye.

• Chemical burns to the eye should be treated with gentle irrigation.

• Ear injuries should be realigned and bandaged. If a part is avulsed, transport with the patient if possible. Stabilize an object that is impaled in the ear.

SummarySummary

• The primary threat from oral or dental trauma is oropharyngeal bleeding and aspiration of blood or broken teeth.

• Aggressively manage injuries involving the anterior neck.

• Patients presenting with sprains or strains should be transported for further evaluation at the emergency department.

CreditsCredits

• Chapter opener: © E. M. Singletary, M.D. Used with permission.

• Backgrounds: Orange—© Keith Brofsky/Photodisc/Getty Images; Purple—Jones & Bartlett Learning. Courtesy of MIEMSS; Red—© Margo Harrison/ShutterStock, Inc.; Green—Courtesy of Rhonda Beck.

• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.

chapter 33 face and neck trauma. national ems education standard competencies trauma integrates...

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