chapter 33 face and neck trauma. national ems education standard competencies trauma integrates...
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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.
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Head, Facial, Neck, and Spine Trauma
Recognition and management of
• Life threats
• Spine trauma
National EMS Education Standard CompetenciesNational 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 CompetenciesNational EMS Education Standard Competencies
Head, Facial, Neck, and Spine Trauma
Pathophysiology, assessment, and management of− Facial fractures
− Skull fractures
− Foreign bodies in the eyes
− Dental trauma
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Head, Facial, Neck, and Spine 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
The Facial BonesThe Facial Bones
• Two major nerves provide control: − Trigeminal nerve
• Ophthalmic nerve
• Maxillary nerve
• Mandibular nerve
− Facial nerve
The Facial BonesThe Facial Bones
• Orbits− Cone-shaped fossae
− Enclose and protect the eyes
The Facial BonesThe Facial Bones
• Nose− Nasal septum
separates the nostrils
− External portion is formed of cartilage
− Paranasal sinuses• Hollowed bone
lined with membranes
The Facial BonesThe Facial Bones
• Mandible− Movable bone forming the lower jaw
• Temporomandibular joint (TMJ) − Allows movement of the mandible
The Facial BonesThe Facial Bones
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
The Anterior Region of the Neck
• Structures:− Thyroid and cricoid
cartilage
− Trachea
− Muscles and nerves
The Anterior Region of the Neck
The Anterior Region of the Neck
• 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.
Primary AssessmentPrimary Assessment
• Airway and breathing− Determine whether air is moving.
− Suction as needed.
− Correct airway patency.
− Assess the patient’s breathing.
Primary AssessmentPrimary Assessment
• Circulation− Palpate the pulse.
− Inspect the skin.
− Control significant bleeding.
− If multiple systems are likely affected, perform a rapid exam.
Primary AssessmentPrimary Assessment
• Transport decision− The following require immediate transport:
• Poor initial general impression
• Altered level of consciousness
• Dyspnea
• Abnormal vital signs
• Shock
• Severe pain
Primary AssessmentPrimary Assessment
• 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.
Secondary AssessmentSecondary Assessment
• Assess the neurologic system.− Level of consciousness
− Pupil size and reactivity
− Motor response
− Sensory response
Secondary AssessmentSecondary Assessment
• Assess the musculoskeletal system. − Look for DCAP-BTLS.
− Assess the chest, abdomen, and extremities.
− Assess the posterior torso.
Secondary AssessmentSecondary Assessment
• 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
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
Pathophysiology of Face Injuries
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
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
Pathophysiology of Face Injuries
• Nasal fractures − Nasal bones are not structurally sound.
− Characterized by: • Swelling
• Tenderness
• Crepitus
Pathophysiology of Face Injuries
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
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
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
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
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 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.
Management of Face InjuriesManagement of Face Injuries
• Assess breathing and intervene appropriately.
• Perform ET intubation.− Cricothyrotomy
may be required.© Eddie M. Sperling
Management of Face InjuriesManagement 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 InjuriesManagement 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 InjuriesManagement 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 InjuriesManagement 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
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
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
Pathophysiology of Eye Injuries
• Blunt eye injuries− Hyphema: bleeding into anterior chamber that
obscures vision
Pathophysiology of Eye Injuries
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
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
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
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 InjuriesAssessment of Eye Injuries
• Note the MOI.
• Ensure a patent airway.
• Control any external bleeding.
• If appropriate, perform a rapid exam.
Assessment of Eye InjuriesAssessment 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 InjuriesAssessment of Eye Injuries
• Symptoms of serious ocular injury:− Visual loss
− Double vision
− Severe eye pain
− A foreign body sensation
Assessment of Eye InjuriesAssessment 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 InjuriesAssessment 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 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.
Management of Eye InjuriesManagement 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 InjuriesManagement 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 InjuriesManagement 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 InjuriesManagement 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 InjuriesManagement 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 InjuriesManagement of Eye Injuries
Courtesy of AAOS Courtesy of AAOS
Courtesy of AAOS Courtesy of AAOS
Management of Eye InjuriesManagement 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
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
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
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
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
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 saline-
moistened gauze.
− Place in plastic bag and place bag on ice.
Assessment and Management of Ear Injuries
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
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
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
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
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
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
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
Pathophysiology of Injuries to the Anterior Part of the Neck
• Soft-tissue injuries (cont’d)− Impaled objects
can present life-threatening problems. • Do not remove
impaled objects unless they interfere with the airway.
Pathophysiology of Injuries to the Anterior Part of the Neck
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
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
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
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
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
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
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.