Download Chapter 33: Face and Neck Trauma

Chapter 33
Face and Neck Trauma
National 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.
National EMS Education
Standard Competencies
Head, Facial, Neck, and Spine Trauma
Recognition and management of
• Life threats
• Spine trauma
National EMS Education
Standard Competencies
Head, Facial, Neck, and Spine Trauma
Pathophysiology, assessment, and
management of
− Penetrating neck trauma
− Laryngotracheal injuries
− Spine trauma
• Dislocations/subluxations
• Fractures
• Sprains/strains
National EMS Education
Standard Competencies
Head, Facial, Neck, and Spine Trauma
Pathophysiology, assessment, and
management of
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−
−
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Facial fractures
Skull fractures
Foreign bodies in the eyes
Dental trauma
National EMS Education
Standard Competencies
Head, Facial, Neck, and Spine Trauma
Pathophysiology, assessment, and
management of
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−
−
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Unstable facial fractures
Orbital fractures
Perforated tympanic membrane
Mandibular fractures
Introduction
• 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 Bones
• 14 facial bones
− Protect the eyes,
nose, and tongue
− Provide attachment
points for the
muscles that allow
chewing
The Facial Bones
• Two major nerves provide control:
− Trigeminal nerve
• Ophthalmic nerve
• Maxillary nerve
• Mandibular nerve
− Facial nerve
The Facial Bones
• Orbits
− Cone-shaped fossae
− Enclose and protect the eyes
The Facial Bones
• Nose
− Nasal septum
separates the
nostrils
− External portion is
formed of cartilage
− Paranasal sinuses
• Hollowed bone
lined with
membranes
The Facial Bones
• Mandible
− Movable bone forming the lower jaw
• Temporomandibular joint (TMJ)
− Allows movement of the mandible
The Facial Bones
The Eye
• Globe: spherical
structure housed
within the orbit
• Oculomotor nerve
− Innervates the
muscles that cause
motion
• Optic nerve
− Provides the sense
of vision
The Eye
• Structures of the eye include:
− Sclera
− Cornea
− Conjunctiva
−
−
−
−
Iris
Pupil
Lens
Retina
The Eye
The 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 Eye
• Two types of vision:
− Central vision
• Visualization of objects directly in front of you
− Peripheral vision
• Visualization of lateral objects
The Ear
• Divided into three anatomic parts
− External ear
− Middle ear
− Inner ear
The Ear
The 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 Teeth
• 32 permanent
teeth
− Distributed about
the maxillary and
mandibular arches
− Four quadrants
The Teeth
• Crown: top portion
of the tooth
• Pulp cavity fills the
center of the tooth
and contains:
− Blood vessels
− Nerves
− Specialized
connective tissue
The Mouth
• Digestion begins
with mastication.
• Tongue: primary
organ of taste
The 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
The Anterior Region of the
Neck
• Major blood
vessels:
− Carotid arteries
− Jugular veins
Scene Size-Up
• Assess and address any hazards.
• Determine the number of patients.
• Consider need for additional resources.
• Evaluate the mechanism of injury (MOI).
Primary 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.
Primary Assessment
• Airway and breathing
− Determine whether air is moving.
− Suction as needed.
− Correct airway patency.
− Assess the patient’s breathing.
Primary Assessment
• Circulation
− Palpate the pulse.
− Inspect the skin.
− Control significant bleeding.
− If multiple systems are likely affected, perform a
rapid exam.
Primary Assessment
• Transport decision
− The following require immediate transport:
• Poor initial general impression
• Altered level of consciousness
• Dyspnea
• Abnormal vital signs
• Shock
• Severe pain
Primary Assessment
• Transport decision (cont’d)
− Other signs that require rapid transport:
• Tachycardia
• Tachypnea
• Weak pulse
• Cool, moist, and pale skin
History 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 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.
Secondary Assessment
• Assess the neurologic system.
− Level of consciousness
− Pupil size and reactivity
− Motor response
− Sensory response
Secondary Assessment
• Assess the musculoskeletal system.
− Look for DCAP-BTLS.
− Assess the chest, abdomen, and extremities.
− Assess the posterior torso.
Secondary Assessment
• Assess all anatomic regions.
• Record pulse, motor, and sensory function.
• Reassess the vital signs.
Reassessment
• Obtain and evaluate vital signs.
• Check interventions.
• Repeat the primary assessment.
Reassessment
• 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 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 softtissue injuries.
Courtesy of Rhonda Beck
Pathophysiology of
Face Injuries
• Soft-tissue injuries (cont’d)
− Impaled objects present risk of airway
compromise.
− Massive oropharyngeal bleeding can result in:
• Airway obstruction
• Aspiration
• Ventilator inadequacy
Pathophysiology of
Face Injuries
• Maxillofacial fractures
− Occur when facial bones absorb strong impact
− When assessing, protect the cervical spine.
− First clue: ecchymosis
Pathophysiology of
Face Injuries
• Nasal fractures
− Nasal bones are not structurally sound.
− Characterized by:
• Swelling
• Tenderness
• Crepitus
Pathophysiology of
Face Injuries
• 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
Pathophysiology of
Face Injuries
• Maxillary fractures
− Produce:
• Massive facial swelling
• Instability of the midfacial bones
• Malocclusion
• Elongated appearance of the face
Pathophysiology of
Face Injuries
• Maxillary fractures (cont’d)
− Le Fort fractures are classified into:
• Le Fort I fracture
• Le Fort II fracture
• Le Fort III fracture
Pathophysiology of
Face Injuries
• Orbital fractures
− Signs and symptoms include:
• Infraorbital hypoesthesia
• Enophthalmos traumaticus
• Massive nasal discharge
• Impaired vision
• Paralysis of upward gaze
Pathophysiology of
Face Injuries
• 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 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 Injuries
• Evaluate the cranial nerve function.
• Visually inspect the oropharynx for signs of
posterior epistaxis.
− Alert the ED to this situation.
Management 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.
Management of Face Injuries
• Assess breathing
and intervene
appropriately.
• Perform ET
intubation.
− Cricothyrotomy
may be required.
© Eddie M. Sperling
Management of Face Injuries
• 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
Management of Face Injuries
• 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.
Management of Face Injuries
• 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.
Management of Face Injuries
• 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
Pathophysiology of
Eye Injuries
• Foreign bodies,
impaled objects
− Foreign objects
can produce
irritation.
• Conjunctivitis:
inflamed and red
conjunctiva
• Eye produces
tears.
Pathophysiology of
Eye Injuries
• Blunt eye injuries
− Hyphema: bleeding into anterior chamber that
obscures vision
Pathophysiology of
Eye Injuries
• Blunt eye injuries
(cont’d)
− Orbital blowout
fractures
• Fragments of bone
can entrap eye
muscles
− Retinal
detachment:
separation of retina
from choroid
Pathophysiology of
Eye Injuries
• Burns of the eye
− Chemical burns require immediate emergency
care.
• Flush with water or a sterile saline solution.
Pathophysiology of
Eye Injuries
• Burns of the eye (cont’d)
− Thermal burns occur when a patient is burned
in the face during a fire.
Pathophysiology of
Eye Injuries
• 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 Injuries
• Note the MOI.
• Ensure a patent airway.
• Control any external bleeding.
• If appropriate, perform a rapid exam.
Assessment of Eye Injuries
• 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?
Assessment of Eye Injuries
• Symptoms of serious ocular injury:
− Visual loss
− Double vision
− Severe eye pain
− A foreign body sensation
Assessment of Eye Injuries
• During physical examination, evaluate:
− Orbital rim: ecchymosis, swelling, lacerations,
tenderness
− Eyelids: ecchymosis, swelling, lacerations
− Corneas: foreign bodies
− Conjunctivae: redness, pus, inflammation,
foreign bodies
Assessment of Eye Injuries
• 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 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.
Management of Eye Injuries
• 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.
Management of Eye Injuries
• 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
Management of Eye Injuries
• Foreign bodies,
impaled objects
− Do not remove a
foreign body
impaled in the
globe.
− Stabilize object.
− Promptly transport
the patient.
Management of Eye Injuries
• 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.
Management of Eye Injuries
• Chemical burns
− Immediately irrigate with water or saline
solution.
− Avoid contaminated water getting into
unaffected eye.
− Irrigate for at least 5 minutes.
Management of Eye Injuries
Courtesy of AAOS
Courtesy of AAOS
Courtesy of AAOS
Courtesy of AAOS
Management of Eye Injuries
• 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.
Pathophysiology of
Ear Injuries
• 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.
Assessment and Management
of Ear Injuries
• If direct pressure does not control bleeding:
− Place dressing between ear and scalp.
− Apply roller bandage.
− Apply ice pack.
Assessment and Management
of Ear Injuries
• 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 salinemoistened gauze.
− Place in plastic
bag and place bag
on ice.
Assessment and Management
of Ear Injuries
• 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
Pathophysiology of Oral and
Dental Injuries
• 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.
Assessment and Management
of Oral and Dental Injuries
• 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.
Pathophysiology of Injuries to
the Anterior Part of the Neck
• Soft-tissue injuries (cont’d)
− Primary threats from penetrating trauma:
• Massive hemorrhage
• Airway compromise
− Air embolisms are associated with open neck
injuries.
Pathophysiology of Injuries to
the Anterior Part of the Neck
• Soft-tissue injuries
(cont’d)
− Impaled objects
can present lifethreatening
problems.
• Do not remove
impaled objects
unless they
interfere with the
airway.
Pathophysiology of Injuries to
the Anterior Part of the Neck
• 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
Assessment of Injuries to the
Anterior Part of the Neck
• 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.
Management of Injuries to the
Anterior Part of the Neck
• 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.
Management of Injuries to the
Anterior Part of the Neck
• Patients may require a surgical or
percutaneous airway.
− Use multiple techniques for confirming correct
ET tube placement.
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 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 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 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 Trauma
• If your examination reveals no obvious MOI,
consider treatment for muscular strain.
− Rest, ice, elevation
− Soft collar
Injury Prevention
• Prevention during activities in which the risk
of being hit is high:
− Helmets
− Face shields
− Mouth guards
− Safety glasses
Injury Prevention
• Advances in motor vehicle safety include:
− Better occupant safety restraints and air bags
− Improvements to the headrests
Summary
• 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.
Summary
• 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.
Summary
• 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.
Summary
• 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.
Summary
• 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.
Credits
• 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.