Chapter 29 Face and Neck Injuries

Massive nasal discharge may occur with orbital fractures

and vision is often impaired

The inner ear is composed of

bony chambers filled with fluid.

Abnormal pupil reactions sometimes are a sign of

brain injury rather than an eye injury

Le Fort fractures can occur as

isolated fractures (Le Fort I) or in combination (Le Fort I and II), depending on: i. Location of impact ii. Amount of trauma

Deformity of the nose, if present, usually appears as

lateral displacement of the nasal bone -Often complicated by the presence of an anterior or posterior nosebleed

•Mandibular fractures typically result from

massive blunt force trauma to the lower third of the face

Lacerations apply

no pressure to the eye

Magnitude of force required to fracture the maxilla

will produce closed head and cervical spine injuries.

After completing the irrigation

•Apply a clean, dry dressing to cover the eye. •Transport the patient promptly to the hospital for further care.

•Facial fractures Clues include:

•Bleeding in the mouth •Inability to swallow or talk •Absent or loose teeth •Loose and/or movable bone fragments

-If the pinna is partially avulsed:

•Carefully realign the ear into position. •Attempt to retrieve the avulsed part for reimplantation. •Do not remove an impaled object from the ear.

•Orbital fractures s/s

•Double vision (diplopia) •Loss of sensation above the eyebrow or over the cheek •Paralysis of upward gaze

-While en route:

•Ensure airway remains open •Administer high-flow oxygen •Obtain vascular access

Injury Prevention

•Helmets, face shields, mouth guards, and safety eyewear help to prevent injury. -Better occupant safety restraints and airbags help to prevent contact with the interior of the vehicle. -Improvements to the headrests reduce the number of neck strains.

-Chemical burns (cont.)

•Irrigate the eye for at least 5 minutes. •Follow local protocols on whether to try to irrigate while transporting or stay on scene.

•Injuries of the neck -Can lead to:

•Loss of voice •Difficulty swallowing •Severe and sometimes fatal airway obstruction •Leakage of air into the soft tissues of the neck

Muscular Injuries 1

•Most of the nonpenetrating injuries are classified as sprains and strains. -Maintain a high index of suspicion for cervical involvement and provide cervical spine stabilization. -Recommended to transport patients to the ED for radiologic studies -If you suspect musculoskeletal injury to the neck, then address any airway, ventilation, and oxygenation considerations.

Muscular Injuries 2

•Prehospital management should focus on preventing further injury by restricting range of motion. -Essential to check distal pulse and sensory and motor function before and after the full-body splint is applied. -Patients reporting neck pain should be evaluated for occult injuries and prevention of long-term consequences.

-Signs and symptoms of larynx injuries:

•Respiratory distress •Hoarseness •Pain •Difficulty swallowing (dysphagia) •Coughing up blood (hemoptysis) •Cyanosis •Pale skin •Sputum in the wound •Subcutaneous emphysema Bruising on the neck

Zygomatic (cheek bone) fractures s/s

•Side of the patient's face that is fractured appears flattened •Loss of sensation over cheek, nose, and upper lip •Paralysis of upward gaze

-Chemical burns

•Stop the burn and prevent further damage. •Flush the eye with clean water or a sterile saline irrigation solution for chemical burns.

•Laryngeal injuries Blunt force trauma to the larynx can occur when

•Unrestrained driver strikes the steering wheel •Snowmobile rider or off-road biker strikes a clothesline or a fixed wire

Maintain a high index of suspicion when a patient presents with

•closed soft-tissue injuries to the face. -Remember that blood is a gastric irritant.

Gentle irrigation usually will

•not wash out foreign bodies stuck to the cornea or lying under the upper eyelid. -Must be removed by a physician -Care involves stabilizing the object and preparing the patient for transport to definitive care

Injuries of the face and neck can often lead to

•partial or complete obstruction of the upper airway.

Penetrating injuries to the neck can cause

•profuse bleeding from laceration of the carotid arteries and jugular veins.

Isolated ear injuries can result in

•sensory impairment and permanent disfigurement. -If local pressure does not control bleeding, apply a roller dressing.

The semicircular hyoid bone

"floats" in the superior aspect of the neck just below the mandible.

Le Fort II fracture

(a) Fracture involving the nasal bone and inferior maxilla (b) Separates the nasal bone and lower maxilla from the facial skull and remainder of the cranial bones

Le Fort III fracture (craniofacial disjunction)

(a) Fracture of all midfacial bones (b) Separates the entire midface from the cranium

Le Fort I fracture

(a) Horizontal fracture of the maxilla (b) Separates the hard palate and lower maxilla from the remainder of the skull

In case of hyphema

(bleeding into the anterior chamber of the eye) obscures all or part of the iris. i. Common in blunt trauma and may seriously impair vision ii. Cover the eye to protect it from further injury iii. Transport the patient to the hospital for further medical evaluation. c. Hyphema or rupture of the globe may signal the presence of a spinal injury. d. Elevate the head of the backboard to approximately a 40° angle to decrease intraocular pressure (IOP) e. Discourage the patient from performing activities that may increase IOP.

•Injuries of the neck

-Any injury to the neck is serious and should be considered life-threatening. -Once the cartilages of the upper airway and larynx are fractured, they do not spring back to their normal position.

•Oral and dental injuries

-Blunt mechanisms typically result from MVCs or direct blows to the mouth or chin. -Primary risk is airway compromise from oropharyngeal bleeding. -Suction the oropharynx as needed, and remove fractured tooth fragments to prevent airway compromise. •Apply direct pressure to stop the bleeding.

•Thermal burns

-Burning of the eyelids requires specialized care -Best to provide prompt transport for these patients without further examination -Cover both eyes with a sterile dressing moistened with sterile saline.

Nasal fractures

-Characterized by swelling, tenderness, and crepitus

The ear

-Complex organ that is associated with hearing and balance

Soft-Tissue Injuries treatment pt 2

-Cover exposed parts with a moist, sterile dressing. -Treat facial lacerations and avulsions as you would any other soft-tissue injury. -Check for bleeding inside the mouth. •Broken teeth and lacerations to the tongue may cause profuse bleeding and obstruction of the upper airway.

•Several factors may contribute to obstruction:

-Direct injuries to the nose and mouth -Injuries may cause teeth or dentures to become dislodged. -Swelling that accompanies direct and indirect injury -The airway may also be affected when the patient's head is turned to the side. -Possible injuries to the brain and/or cervical spine 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. -Depending on the mechanism of injury (MOI), there may be a cervical spine injury.

Injuries of the Ear

-Do not try to manipulate any foreign body in the external auditory canal.

Soft tissue injuries

-Face and neck are extremely vascular. Bleeding from penetrating injuries may be heavy. -Presence suggests the potential for more severe injuries

•Light burns to the eyes

-Infrared rays, eclipse light, and laser burns all can cause significant damage.

The eye

-Located within a bony socket called the orbit

•Blast injuries

-Management depends on the severity of the injury. •If a foreign body is embedded 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 protocol.

•Contact lenses and artificial eyes

-Never attempt to remove a lens from an eye that may have been injured. -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. Lift it off the surface of the eye.

•Injuries of the nose

-Nosebleeds are categorized based on the bleeding area. •Anterior nosebleeds usually originate from the area of the septum and bleed fairly slowly. •Posterior nosebleeds are usually more severe and often cause blood to drain into the patient's throat. -Picture the inside of the nose itself to help in assessment. -Assess all structures of the nose for injury.

•Maxillary fractures

-Occur with mechanisms that produce massive blunt facial trauma

•Retinal detachment

-Painless, but produces flashing lights, specks, or "floaters" in field of vision -Requires urgent medical attention to preserve vision.

•Orbit fracture

-Place the patient on a stretcher and transport promptly to the ED. -Protect the eye with a metal shield. -Cover the other eye to minimize eye movement.

Injuries of the Neck

-Possibility of a fatal air embolism -A large amount of air entrained into heart can lead to cardiac arrest. -Immediately seal open neck wounds with an occlusive dressing. -Use caution to avoid constricting the vessels and structures of the neck. -Be alert for swelling and expanding hematomas.

•Eye injuries following head injury

-Possibility of a head injury if one pupil is larger than the other -For an unresponsive patient, keep the eyelids closed. -Drying of the ocular tissues may result in blindness. •Cover the lids with moist gauze.

•To manage a laryngeal injury:

-Provide oxygenation and ventilation. -Apply cervical immobilization. -Be alert to the need for frequent suctioning. -Do not delay transport. -Call for paramedic rendezvous for advanced airway management, especially if the patient is apneic.

Lacerations

-Require very careful repair to restore appearance and function.

Soft-Tissue Injuries treatment pt 2 3

-Wrap portions of avulsed skin that have become separated in a sterile dressing moistened with saline and place them in a plastic bag in a cool temperature. •Never place tissue directly on ice.

An incident involving an injury to the throat may also have caused

-a cervical spinal injury. Spinal stabilization may be needed

Teeth fragments can become an

-airway obstruction and should be removed immediately. -Leave well-fitting dentures in place.

Leave impaled objects in the face in place and

-appropriately stabilize them, unless they pose a threat to the airway.

•Zygomatic (cheek bone) fractures Commonly result from

-blunt trauma in MVCs and assaults

Subcutaneous emphysema is a

-characteristic crackling sensation produced by the presence of air in the soft tissues of the neck. •Maintain the airway as best you can and transport immediately.

Facial fractures Occur when the

-facial bones absorb the energy of a strong impact

Lacerations--- If part of the eyeball is exposed,

-gently apply a moist, sterile dressing.

Foreign bodies may be

-impaled in the eye. •Your care involves stabilizing the object and preparing the patient for transport.

When dealing with an avulsed tooth, handle it by

-its crown and not by the root. •Do not allow the tooth to dry. •Notify the receiving facility.

Signs and symptoms of a perforated tympanic membrane include

-loss of hearing and blood drainage from the ear. -Careful assessment should be performed to detect and treat other injuries.

Dental injuries May be associated with

-mechanisms that cause severe maxillofacial trauma or they may occur in isolation

•Mandibular fractures---The fracture site itself is

-most commonly located at the angle of the jaw.

Oculomotor nerve innervates the

-muscles and carries parasympathetic nerve fibers.

Penetrating or impaled objects in the larynx should

-not be removed unless they interfere with cardiopulmonary resuscitation. •Stabilize all impaled objects if they are not obstructing the airway.

light burns to the eyes are

-not painful but may become so 3 to 5 hours later.

Apply pressure above and below the

-penetrating wound to control life-threatening bleeding. -Do not remove impaled objects.

Epistaxis following facial trauma can be

-severe and is most effectively controlled by applying direct pressure to the nares. -Control bleeding from abrasions and lacerations to the nose by applying a sterile dressing.

For severe oropharyngeal bleeding in patients with inadequate ventilation

-suction the airway for 15 seconds and provide ventilatory assistance for 2 minutes.

Facial fractures alone are not acute emergencies unless

-there is serious bleeding. -Plastic surgeons can repair the damage to the face and mouth if the injuries are treated within 7 to 10 days.

Treatment starts with a

-thorough examination. •Take care not to aggravate any problems. Look for specific abnormalities or conditions

Objectives when treating a patient with face and neck injuries

Prevention of further injury (particularly to the cervical spine) - Managing any acute airway problems - Controlling bleeding

With light burns to the eyes

Severe conjunctivitis usually develops with redness, swelling, and excessive tear production

Divided into three parts

The external ear The middle ear The inner ear

Inner surface of the eyelids and the exposed surface of the eye are covered by

conjunctiva

light burns to the eyes Ease the pain by

covering each eye with a sterile, moist pad and an eye shield

The head is divided into two parts

cranium and face

Face is composed of

eyes, ears, nose, mouth, cheeks

When assessing a patient with a suspected

facial fracture, protect the cervical spine, and monitor neurologic signs, specifically the level of consciousness.

Irrigation with a sterile saline solution will

frequently flush away loose, small foreign particles.

Face and neck are

frequently subjected to traumatic forces

General signs/symptoms of facial fractures:

i. Deep facial laceration ii. Pain over a bone iii. Ecchymosis iv. Swelling v. Pain on palpation vi. Crepitus vii. Misalignment of teeth viii. Facial deformities or asymmetry ix. Instability of facial bones x. Impaired ocular movement xi. Visual disturbances

On rare occasions, the eyeball may be displaced from its socket.

i. Do not attempt to manipulate or reposition it. ii. Cover the eye and stabilize it with a moist sterile dressing. iii. Cover both eyes to prevent further injury because of sympathetic eye movement. iv. Have the patient lie supine to prevent loss of fluid from the eye.

The facial skeleton is composed of six major bones:

i. Nasal bone ii. Two maxillae (upper jawbones) iii. Two zygomas (cheekbones) iv. Mandible (jawbone) c. The orbit of the eye is composed of: i. Lower edge of the frontal bone of the skull ii. Zygoma iii. Maxilla iv. Nasal bone

•Mandibular fractures---"Point tenderness" and pain on motion can identify

injuries that patients might not have otherwise reported.

Soft-Tissue Injuries Emergency care must focus on Soft-Tissue Injuries treatment pt 1

protecting the airway. -Assess the ABCDEs and care for any life threats first. -Use the jaw-thrust maneuver to open the patient's airway, and then suction the mouth. -Control external bleeding by applying direct manual pressure.

Lacerations--- Cover the injured eye with a

protective metal eye shield, cup, or sterile dressing

Normal pupils are

round usually equal in size, and react equally when exposed to light.

Penetrating trauma to the neck may cause

severe bleeding. An open injury may allow an air embolism to enter the circulatory system.

Bandage both eyes with

soft bulky dressings to prevent further injury to the affected eye.

Cranium contains

the brain

The external ear is composed of

the pinna and the external auditory canal

Opening in the center of the iris is

the pupil

Optic nerve provides

the sense of vision

Motion of the mandible occurs at the

the temporomandibular joint, which lies just in front of the ear on either side of the face.

The middle ear contains

three small bones—the malleus, incus, and stapes.