Trauma Part V - Face & Neck Trauma

1. Scene size-up

*Same as the medical assessment except for MOI 1. Assess and address any hazards. 2. Assess for the potential for violence. 3. Ensure standard precautions have been taken before you approach the scene. 4. Determine the number of patients. 5. Consider whether you need additional or specialized resources. 6. Evaluate the mechanism of injury (MOI).

9. Reassessment

- Frequent reassessments should be made en route to the hospital. 1. Obtain and evaluate vital signs. 2. Check interventions. 3. Monitor the patient's condition. 4. Repeat the primary assessment. 5. Documentation should include: a. Description of the MOI b. Position in which you found the patient c. Location and description of injuries d. Accurate account of treatment 6. In patients who have open injuries with severe external bleeding, estimate and report the amount of blood loss.

Classification of neck injuries by dividing the neck into zones

1. Injuries in zone I can extend into the chest and may not be easily recognized on physical examination. a. Associated with the highest mortality rate 2. Injuries in zone II are the most common, usually the most obvious, and have a lower mortality rate. 3. Injuries in zone III often are difficult for a surgeon to access and repair because many of the structures enter the base of the skull.

Assessment

1. It is not important to distinguish among the various maxillofacial fractures in the prehospital setting. 2. Assessment is primarily clinical. a. You will observe with sight and touch instead of diagnostic equipment. 3. Pay attention to: a. Swelling b. Deformity c. Instability d. Blood loss 4. Evaluate the cranial nerve function. 5. Visually inspect the oropharynx for signs of posterior epistaxis. a. Signs include frank blood trickling down the back of the throat after a simple anterior epistaxis has been controlled. b. Alert the ED to this situation.

Management of Lacerations and blunt trauma

Bleeding control and gentle patching of the eye. i. Patients should be transported to the hospital. ii. Bleeding can usually be controlled by gentle, manual pressure. (a) Do not apply pressure to the globe because this could result in loss of vision. b. Examine the eye by inverting the upper and lower eyelids to look for the source of corneal abrasion, looking for a foreign body in the eye. c. Irrigation may help remove the object. i. A topical anesthetic like tetracaine can relieve some symptoms of corneal abrasion. ii. A lubricant can resolve some of the pain. iii. You may need to cover both of the patient's eyes to prevent sympathetic eye movement. d. Most injuries to the globe are best treated in the ED. i. Rigid eye shields are generally all that are necessary in the field. e. When treating penetrating injuries of the eye: i. Never exert pressure on or manipulate the injured globe. ii. If part of the globe is exposed, gently apply a moist, sterile dressing to prevent drying. iii. Cover the injured eye with a protective metal eye shield, cup, or sterile dressing. iv. Apply soft dressings to both eyes and provide prompt transport. f. If hyphema or rupture of the globe is suspected, take spinal motion restriction precautions. i. Elevate the head of the backboard approximately 40° to decrease intraocular pressure. ii. If there are no other contraindications, transportation should be performed in the Fowler position. iii. Both eyes should be patched. g. If the globe is displaced out of its socket, do not attempt to manipulate or reposition it! i. Cover the protruding eye with a moist, sterile dressing. ii. Stabilize both eyes to prevent further injury caused by sympathetic eye movement. iii. Place the patient in a supine position and provide prompt transport.

Chemical burns

Chemical burns require immediate emergency care. i. Chemical burns are usually caused by acid or alkali solutions. ii. The patient usually has a loss of vision and shows evidence of facial skin burns. iii. An acid burn generally causes immediate epithelial damage to the cornea. (a) The cornea will appear white and opaque. iv. Alkalis can pass into the anterior chamber of the eye rapidly, exposing the iris, ciliary body, lens, and other structures to further damage. v. Flush the eye with water or a sterile saline solution. (a) If not available, use any clean water for this purpose. c.

Infrared rays, eclipse light, and laser burns of the eye

Infrared rays, eclipse light, and laser burns can cause significant damage to sensory cells. i. Retinal injuries are generally not painful but may result in permanent damage to vision.

Major blood vessels in the anterior region of the neck

Major blood vessels in this area are: a. Internal and external carotid arteries b. Internal and external jugular veins -Vertebral arteries run laterally to the cervical vertebrae in the posterior part of the neck & supply oxygenated blood

Injury prevention

Many improvements and advancements have been made in providing protection to the face and neck. 1. To prevent injury during activities in which the risk of being hit is high, the following are used: a. Helmets b. Face shields c. Mouth guards d. Safety glasses 2. Advances in motor vehicle safety include: a. Better occupant safety restraints and air bags b. Improvements to the headrests

The anterior region of the neck:

Pic

Commonly associated with trauma to the face

Primary risks associated with oral and dental injuries: a. Airway compromise from oropharyngeal bleeding b. Occlusion by a displaced dental appliance c. Occlusion by aspiration of avulsed or fractured teeth

The neck

Principal structures include: a. Thyroid and cricoid cartilage b. Trachea c. Numerous muscles and nerves -Injury to any of the major vessels can produce: a. Cerebral hypoxia b. Infarct c. Air embolism d. Permanent neurologic impairment -Other key structures include: a. Vagus nerves b. Thoracic duct c. Esophagus d. Thyroid and parathyroid glands e. Lower cranial nerves f. Brachial plexus g. Soft tissue and fascia h. Various muscles

Superficial burns of the eye

Superficial burns of the eye can result from ultraviolet rays. i. These burns may not be painful initially but may become so 3 to 5 hours later. ii. Severe conjunctivitis usually develops, along with: (a) Redness (b) Swelling (c) Photophobia (d) Sensation of foreign object in the eye (e) Excessive tear production

The teeth and mouth

The adult mouth normally contains 32 permanent teeth. ---> Teeth are found in alveoli (bony sockets). ---> When subjected to enough force, the teeth can be dislodged during a traumatic insult to the face = Loose teeth that obstruct the airway can be life-threatening.

The Eye

The globe, or eyeball, is susceptible to a variety of injuries, including foreign objects, impalements, and burns. -Movement is controlled by the extraocular muscles, which are controlled by several cranial nerves = The oculomotor nerve is the third cranial nerve. ---> Innervates the muscles that cause motion of the eyeballs and upper eyelids ---> Carries parasympathetic nerve fibers that cause constriction of the pupil and accommodation of the lens The optic nerve does not control movement but provides the sense of vision. When assessing for injury of the eye, evaluate: 1. Sclera 2. Cornea 3. Conjunctiva 4. Iris 5. Pupil

The orbits

The orbits are formed by seven thin bones. ---> Help reduce the weight of the head ---> Vulnerable in nature = A blowout fracture can occur if enough force is applied.

14 facial bones:

i. Nasal bones ii. Ethmoid bone iii. Vomer bone iv. Maxillae v. Parietal bone vi. Frontal bone vii. Sphenoid bone viii. Temporal bone ix. Lacrimal bone x. Zygomatic bone xi. Middle and inferior nasal concha xii. Mandible

Thermal burns

occur when a patient is burned in the face during a fire.

PATHOPHYSIOLOGY, ASSESSMENT, AND MANAGEMENT OF ORAL AND DENTAL INJURIES

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PATHOPHYSIOLOGY, ASSESSMENT, AND MANAGEMENT OF SPINE TRAUMA

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PATHOPHYSIOLOGY, ASSESSMENT, & MANAGEMENT OF EYE INJURIES

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PATHOPHYSIOLOGY, ASSESSMENT, AND MANAGEMENT OF EAR INJURIES

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PATHOPHYSIOLOGY, ASSESSMENT, AND MANAGEMENT OF FACE INJURIES

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PATIENT ASSESSMENT

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THE EYES, EARS, & Mouth

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8. Secondary assessment

- In some cases, you may not have time for a secondary assessment. In other cases, it may occur en route to the ED. 1. Perform using the techniques of inspection and palpation; observe for: a. Drainage from the ears or nose (note if it is bloody or clear) b. The presence of periorbital ecchymosis c. The presence of retroauricular ecchymosis d. Symmetry of the face, including the eyes, ears, skull, and ability to smile e. Deformity, soft-tissue injuries, lumps, or hemorrhage to the head or neck f. Swelling, occlusion, and asymmetrical narrowing at the ear openings g. Lacerations, bite marks, missing teeth h. Evidence of dehydration 2. Additional assessment items include: a. The position and condition of the uvula, the posterior pharynx, and the condition of the mouth, oral mucosa, teeth, gums, and tongue. b. Evaluate the patient's gaze, noting if it is focused, distant, conjugate, or disconjugate. i. Ask about visual disturbances such as diplopia. c. Observe the position and coloration of the eyes ---> Look for any evidence of trauma or infection. d. Assess the pupils. ---> Direct and indirect pupillary reflexes ---> Extraocular movements ---> The presence of a nystagmus. e. Assess the visual fields and for the presence of any visual field defects such as a hemianopsia (also called a hemianopia). f. Inspect the neck for jugular venous distention. g. Note the presence of any enlarged lymph nodes on the neck. 3. Palpate the face and neck, asking the patient to report any pain or tenderness during palpation and note any of the following findings: a. Any deformities, bony instability, lumps, or depressions of the skull b. Soft-tissue injury hidden by the hair c. Bony instability on the face d. Bony instability on the mandible or the temporomandibular junction e. Any enlargement or tenderness of the lymph nodes f. Tracheal deviation of the neck

Maxillofacial fractures

- Occur when the facial bones absorb the energy of a strong impact. - Forces involved are also likely to produce traumatic brain injuries (TBI) and cervical spine injuries. a. When assessing, protect the cervical spine. b. Monitor the patient's neurologic signs (specifically level of consciousness). b. The first clue of a maxillofacial fracture is usually ecchymosis. c. Signs and symptoms include: i. Ecchymosis ii. Swelling iii. Pain to palpation iv. Crepitus v. Dental malocclusion vi. Facial deformities or asymmetry vii. Instability of the facial bones viii. Impaired ocular movement ix. Visual disturbances

Soft-tissue injuries

- Open soft-tissue injuries to the face can indicate the potential for more severe injuries. -Massive soft-tissue injuries to the face can compromise the airway ---> Maintain a high index of suspicion with closed soft-tissue injuries to the face. ---> Impaled objects in the soft tissues or bones of the face present a high risk of airway compromise. ---> Massive oropharyngeal bleeding can result in: a. Airway obstruction b. Aspiration c. Ventilatory inadequacy ---> Blood is a gastric irritant - Ingestion may lead to vomiting, increasing the likelihood of aspiration.

6. Transport decision

- Patients with physiologic findings should be rapidly transported. -Intervention that can be done en route should be delayed until after any immediate life threats have been addressed. -Patients with isolated injuries are often better managed by carefully treating the injuries on scene.

Soft-tissue injuries to the anterior part of the neck

. Be alert for cervical spine injury and airway compromise. b. Common mechanisms of blunt trauma include: i. Motor vehicle crashes ii. Direct trauma to the neck iii. Hangings c. Blunt trauma often results in: i. Swelling and edema ii. Injury to the various structures iii. Injury to the cervical spine d. Be prepared to initiate aggressive management of blunt injuries. e. Common mechanisms of penetrating trauma include: i. Gunshot wounds ii. Stabbings iii. Impaled objects f. Primary threats from penetrating trauma are: i. Massive hemorrhage from major blood vessel disruption ii. Airway compromise from swelling or direct damage g. Air embolisms are associated with open neck injuries. i. Exposed jugular veins may suck air into the vessel and occlude blood flow. ii. Seal with an occlusive dressing immediately. iii. Avoid constriction of the vessels and structures of the neck. iv. Be alert for swelling and expanding hematomas. h. Impaled objects can present several life-threatening problems. i. Do not remove impaled objects. i. Stabilize and protect from movement. ii. The only exception is if the object is obstructing the airway or impeding the ability to manage the airway. iii. Emergency cricothyrotomy may be necessary.

Management of Anterior part of the Neck

1. Always treat the injuries that will be the most rapidly fatal. 2. Perform a rapid exam to detect and treat other injuries. 3. To control bleeding from an open neck wound, immediately cover the wound with an occlusive dressing. a. Electrocardiography electrodes can be a fast and effective way to seal a small hole or holes. b. Apply direct pressure over the occlusive dressing with a bulky dressing. c. Secure a pressure dressing by wrapping roller gauze loosely around the neck and then firmly through the opposite axilla. 4. Monitor the patient's pulse for reflex bradycardia. a. Indicates parasympathetic nervous stimulation due to excessive pressure on the carotid artery 5. If signs of shock are present: a. Administer oxygen as necessary to maintain saturation level of 94% or higher. b. Keep the patient warm. c. Establish vascular access with at least one 18-gauge IV. d. Infuse an isotonic crystalloid solution as needed. i. Maintain a systolic blood pressure of 80 to 90 mm Hg. 6. Patients with serious laryngeal trauma may require a surgical or percutaneous airway. a. Consult your local protocols. b. ET intubation may be hazardous because the tip of the ET tube may pass through a defect in the laryngeal or tracheal wall. i. Signs of this complication include: (a) Increased swelling of the neck (b) Worsening subcutaneous emphysema during ventilation 7. In an open tracheal wound, a cuffed ET tube may be able to pass through the wound to establish a patent airway. a. Use caution—the trachea may be perforated both anteriorly and posteriorly. b. Use multiple techniques for confirming correct ET tube placement:

Emergency medical care

1. Assess bandaging frequently ---> If blood soaks through bandages, use additional methods to control bleeding. 2. Expose wounds, control bleeding, and be prepared to treat for shock. 3. Evaluate all patients with major closed soft-tissue injury to see if they need supplemental oxygen ---> Maintain an oxygen saturation level of 94% or greater.

Assessment of injures to the anterior part of the neck:

1. Common signs associated with injuries to the anterior part of the neck include: a. Bruising b. Redness to the overlying skin c. Palpable tenderness 2. Note the MOI and maintain a high index of suspicion. 3. If the patient is unresponsive, manually stabilize the patient's head in a neutral in-line position and open the airway with the jaw-thrust maneuver. a. Use suction as needed. 4. Assess the patient's breathing. a. If adequate, apply a nonrebreathing mask at 15 L/min. b. If inadequate, assist with bag-mask ventilation and 100% oxygen.

Be familiar with the location of the different types of teeth and their components, including:

1. Crown 2. Cusps 3. Pulp 4. Dentin

3. General impression

1. Determine whether life threats are present. 2. Check for responsiveness even if a soft-tissue injury to the head does not seem significant. 3. Listen for obvious respiratory sounds as you approach the patient. ---> Sonorous respirations usually indicate a positional problem. ---> Gurgling respirations often indicate a need for suction.

2. Primary survey

1. Distracting soft-tissue injuries 2. General impression 3. Airway and breathing 4. Circulation 5. Transport decision

Assessment & Management of Dental Injuries

1. Ensure airway patency and adequate breathing. a. Suction the oropharynx as needed. b. Remove fractured tooth fragments. c. Apply spinal motion restriction precautions as dictated by the MOI. d. If profuse oral bleeding is present and the patient cannot control his or her own airway, pharmacologically assisted intubation may be necessary. 2. Impaled objects in the soft tissues should be stabilized in place unless they interfere with breathing or ability to manage the airway. 3. Medical control may ask you to reimplant an avulsed tooth. a. Place the tooth in its socket. b. Hold it in place or have the patient bite down. c. If prehospital reimplantation is not possible, follow the guidelines established by the American Association of Endodontists and the American Dental Association. 4. If the patient is unstable, airway management, spinal precautions, and rapid transport are most important, with the dental problems addressed at a later time.

Assessment and management of ear emergencies

1. Ensure airway patency and breathing adequacy. 2. If MOI suggests a potential for spinal injury, apply full spinal motion restriction precautions. 3. If manual direct pressure does not control bleeding: a. Place a soft, padded dressing between the ear and the scalp. b. Apply a roller bandage to secure the dressing in place. c. Apply an ice pack to reduce swelling and pain. 4. If the pinna is partially avulsed: a. Realign the ear into position. b. Gently bandage it with padding that has been slightly moistened with normal saline. 5. If the pinna is completely avulsed: a. Attempt to retrieve the avulsed part for reimplantation at the hospital. i. Wrap it in saline-moistened gauze. ii. Place it in a plastic bag. iii. Place the bag on ice. (a) If a chemical ice pack is used, shield the avulsed part with several gauze pads. 6. If blood or CSF drainage is noted: a. Apply a loose dressing over the ear. i. Take care not to stop the flow. b. Assess the patient for signs of a basilar skull fracture. 7. Do not remove an impaled object from the ear. a. Stabilize the object. b. Cover the ear to prevent gross movement and minimize the risk of contamination. 8. Perform a careful assessment to detect or rule out more serious injuries before proceeding with specific care.

Assessment of Eye Injuries

1. Note the MOI. 2. Ensure a patent airway and adequate breathing. 3. Control any external bleeding. 4. If appropriate, perform a rapid full-body exam. 5. When obtaining the history, ask: a. How and when did the injury happen? b. When did the symptoms begin? c. What symptoms is the patient experiencing? d. Were both eyes affected? e. Does the patient take medications for his or her eyes? f. Does the patient have any diseases or conditions of the eye? 6. Symptoms that indicate serious ocular injury include: a. Visual loss that does not improve when the patient blinks i. May indicate damage to the globe or optic nerve b. Double vision i. Usually points to trauma involving the extraocular muscles c. Severe eye pain d. A foreign body sensation 7. Begin with a thorough examination to determine the extent and nature of the damage. a. Check whether the eye can move to the six cardinal positions of gaze: right, right up, right down, left, left up, and left down. 8. During the physical examination, evaluate each of the ocular structures and function. a. Orbital rim: ecchymosis, swelling, lacerations, and tenderness b. Eyelids: ecchymosis, swelling, and lacerations c. Corneas: foreign bodies d. Conjunctivae: redness, pus, inflammation, and foreign bodies e. Globes: redness, abnormal pigmentation, and lacerations f. Pupils: size, shape, equality, and reaction to light g. Eye movements in all directions: paralysis of gaze or discoordination between the two eyes h. Visual acuity: patient's ability to read a newspaper or a hand-held visual acuity chart 9. Eye injuries are usually not life threatening but should be evaluated by a physician or ophthalmologist.

5. Circulation

1. Palpate the pulse for its presence, rate, regularity, and quality. 2. Assess skin CTC (color, temperature, and condition). 3. Control any visible significant bleeding. 4. Reevaluate the patient's mental status and response to stimuli. a. Note any changes since initial contact. b. Evaluate the presence or absence of pulse, motor function, and sensory function in each extremity. c. Inquire about any numbness or tingling (paresthesia) to the extremities. d. Directly observe the back to assess for penetrating trauma. e. Palpate the spinal column for deformity, step-offs, point tenderness, or crepitus.

Management of Spine Trauma

1. Patients reporting neck pain after injury should be evaluated in the ED. 2. Address any airway, ventilation, and oxygenation considerations. 3. Prevent further injury with motion restrictions. 4. If your examination reveals no obvious MOI, consider treatment as you would for any other muscular strain. a. This includes rest, ice, and elevation. b. A soft collar may support the head and strained muscles. c. Patients reporting neck pain should still be evaluated for occult injuries.

Management

1. Protect the cervical spine. a. Open the airway with the jaw-thrust maneuver while maintaining manual stabilization of the head in the neutral position. i. If the patient reports severe pain or discomfort upon movement, immobilize the head and neck in the position found. 2. Inspect the mouth for objects that could obstruct the airway, and remove them. 3. Suction the oropharynx as needed. 4. Insert an airway adjunct as needed. a. Unless absolutely necessary, insertion of a nasopharyngeal airway should not be performed in any patient with: i. Suspected nasal fractures ii. CSF or blood leakage from the nose iii. Evidence of midface trauma, unless it is absolutely necessary 5. Assess the patient's breathing and intervene appropriately. a. If the patient is breathing adequately, administer oxygen as needed. b. Patients who are breathing inadequately should receive bag-mask ventilation with 100% oxygen. c. Maintain oxygen saturation at greater than 94%. 6. Perform endotracheal intubation of patients with facial trauma. a. Protects airway from aspiration b. Ensures adequate oxygenation and ventilation c. In-line cervical spinal motion restriction during ET intubation d. If ET intubation is extremely difficult or impossible: i. Surgical or needle cricothyrotomy 7. Foreign bodies in the throat create the potential for airway obstruction and aspiration. a. Transport the patient in a position of comfort. 8. Treat facial lacerations and avulsions the same as other soft-tissue injuries. a. Control all bleeding with direct pressure and apply sterile dressings. b. Leave impaled objects in the face unless they pose a threat to the airway. c. For severe oropharyngeal bleeding with inadequate ventilation: i. Suction the airway for 15 seconds. ii. Provide ventilatory assistance for 2 minutes. iii. Continue alternating until the airway is cleared of blood or secured. d. Epistaxis is most effectively controlled by applying direct pressure to the nares. i. If the patient is responsive and spinal immobilization is not indicated, instruct the patient to sit up and lean forward as you pinch the nares together. ii. Unresponsive patients should be positioned on their side. iii. If the responsive patient is immobilized on a backboard, consider drug-assisted assisted intubation. iv. Carefully assess for signs of hemorrhagic shock. 9. Cold compresses may help reduce swelling and alleviate the pain of maxillofacial fractures. a. Do not apply to the eyeball if you suspect injury following an orbital fracture. i. May increase intraocular pressure ii. May stimulate the oculocardiac reflex

Pathophysiology of spine trauma

1. The neck is subject to injury that may not result in bony injury. a. Sprain: stretching or tearing of ligaments b. Strain: stretching or tearing of muscle or tendon c. Cervical precautions should be taken.

Assessment of Spine Trauma

1. Transport patients to the ED for radiologic studies. 2. Conduct a visual inspection for signs of soft-tissue injury. 3. If the patient is symptomatic with pain, maintain spinal stabilization. 4. If the MOI dictates spinal clearance protocol and your examination produces pain or resistance: a. Stop the examination. b. Maintain spinal stabilization. c. Transport the patient for further evaluation in the ED.

7. History taking

1. Was there a precipitating factor? ---> Consider a medical reason that led to the trauma. 2. Ask the patient or family members and bystanders about the injury, such as: a. Was the patient wearing a seat belt? b. Was there an airbag deployment? c. How fast was the vehicle traveling? d. How high is the location from which the patient fell? e. Was there a loss of consciousness? f. Which type of weapon was used? 3. Record the information on the patient care record, and relay it during patient transfer. ---> Attempt to obtain a SAMPLE history. 4. If your patient is unresponsive and bystanders cannot provide information, your only sources of information may be: a. The scene b. Medical alert jewelry

PATHOPHYSIOLOGY, ASSESSMENT, AND MANAGEMENT OF INJURIES TO THE ANTERIOR PART OF THE NECK

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4. Airway and breathing

Assess the airway as soon as you arrive at the patient's side. 1. If the patient has a potential neck or spine injury, assign a crew member to perform manual stabilization while the airway is being assessed. a. Maintain immobilization until it is determined that spinal precautions are not indicated. b. If precautions are indicated, maintain until full spinal immobilization has been applied. 2. If the patient is unresponsive or has a significantly altered level of consciousness, consider using an airway adjunct. 3. When blood, vomit, or any other substance is present in the airway, immediately suction from the airway. 4. Assess the patient's breathing and its adequacy, employing corrective measures as needed. 5. Closely assess for signs of hypoxia. 6. Assess for and treat any life-threatening injuries that may compromise ventilation.

The Ear

Divided into three anatomic parts 1. External ear, consisting of: a. Pinna b. External auditory canal 2. Middle ear, consisting of: a. Tympanic membrane b. Malleus c. Incus d. Stapes 3. Inner ear, consisting of: a. Semicircular canals b. Oval window c. Vestibular nerve d. Cochlear nerve e. Vestibule f. Round window g. Eustachian (auditory) tube -Treatment of injuries involving the external ear by paramedics -Injuries to the middle ear = May be visible but are difficult to treat in the field -Injuries to the inner ear ---> Complaints of vertigo ---> Generally cannot be treated in the prehospital setting

Distracting soft-tissue injuries

Do not take your focus off the ABCDE. If there is life-threatening bleeding or cardiac arrest, the order would be CABD

Orbital fractures

a. An orbital blowout fracture involves the bones of the orbital floor. i. Typical MOI involves a fist, dashboard, or baseball striking the globe of the eye and surrounding soft tissues. b. The patient may report diplopia. c. The patient may lose sensation above the eyebrow or over the cheek. d. Signs and symptoms include: i. Infraorbital hypoesthesia: Reduced sensation to areas that are innervated by the infraorbital nerve ii. Enophthalmos traumaticus: posterior eyeball retraction into the space created iii. Massive nasal discharge and possibly CSF iv. Impaired vision v. Paralysis of upward gaze (found with fractures of the inferior orbit) e. Treatment of an isolated orbital fracture is primarily supportive. i. If the globe has been ruptured, place a rigid eye shield over the affected eye and bandage both eyes.

Management of burns in the eye

a. Burns caused by ultraviolet light: i. Cover the eye with a sterile, moist pad and an eye shield ii. Apply cool compresses lightly over the eye if patient is in extreme distress iii. Place the patient in a supine position during transport b. Chemical burns: i. Immediately irrigate with sterile water or saline solution. ii. If only one eye is affected, avoid getting contaminated water into the unaffected eye. iii. Irrigate for at least 5 minutes. (a) If burn was caused by an alkali or strong acid, irrigate continuously for 20 minutes. c. Continue irrigation en route to the hospital. i. Control any contaminated runoff. d. Local protocol will direct you to specialized treatments for burns to the eyes.

Ruptured eardrum

a. Can result from: i. Direct blows ii. Foreign bodies in the ear iii. Pressure-related injuries (a) Blast injuries (b) Diving-related injuries b. Signs and symptoms include: i. Loss of hearing ii. Blood drainage from the ear c. The tympanic membrane typically heals spontaneously.

Management of foreign bodies and impaled objects

a. Carefully evaluate the entire eye using a light. i. Note any blood or discoloration of the sclera b. You might be able to remove the object if it is on the surface of the eyelid with a moist, sterile, cotton-tipped applicator. i. Never attempt to remove a foreign body that is stuck or imbedded in the cornea. ii. Irrigate the eye with a sterile saline solution to relieve pain and assist with dislodging the foreign body. c. When a foreign body is impaled in the globe, do not remove it! d. Stabilize the object. i. Cover the eye with a moist, sterile dressing. ii. Place a cup or protective barrier over the object, and secure it in place with bulky dressing. iii. Cover the unaffected eye to prevent further damage. e. Promptly transport the patient.

Nasal fractures

a. Characterized by: i. Swelling ii. Tenderness iii. Crepitus b. Often complicated by an anterior or a posterior nosebleed that can compromise the airway

Zygomatic fractures

a. Commonly result from blunt trauma. b. Signs and symptoms include: i. Flattened appearance on face ii. Loss of sensation over the cheek, nose, and upper lip iii. Paralysis of upward gaze c. Associated injuries include: i. Orbital fractures ii. Ocular injury iii. Epistaxis

Lacerations, foreign bodies, and impaled objects

a. Compression to the globe can: i. Interfere with blood supply and result in loss of vision ii. Squeeze the vitreous humor, iris, lens, or retina out of the eye and cause irreparable damage b. Foreign objects lying on the surface of the eye can produce severe irritation. i. The conjunctiva becomes inflamed and red (conjunctivitis). ii. The eye produces tears in an attempt to flush out the object. iii. Irritation of the cornea causes intense pain. iv. Irritation is often further aggravated by bright light. v. Most objects are easily flushed out. (a) Rust and metal cannot be removed by flushing and require removal by a physician.

Soft-tissue injuries pathophysiology

a. Lacerations and avulsions are associated with a risk of: i. Intraoral hemorrhage ii. Subsequent airway compromise b. Assessment of any patient with facial trauma should include a careful examination of the mouth. c. Fractured or avulsed teeth and lacerations of the tongue may cause profuse bleeding into the upper airway. d. A responsive patient with severe oral bleeding is often unable to speak unless he or she is leaning forward. i. Position facilitates drainage of blood from the mouth e. Patients may swallow blood from lacerations inside the mouth. i. Risks of vomiting and aspiration are significant f. Objects impaled in or through the soft tissues of the mouth can result in profuse bleeding. i. Risks of vomiting and aspiration

Soft-tissue injuries pathology

a. Lacerations, avulsions, and contusions to the external ear can occur following blunt or penetrating trauma. b. The pinna has a poor blood supply, so it tends to heal poorly. i. Healing is often complicated by infection.

Dental injuries pathophysiology

a. May be associated with mechanisms that cause severe maxillofacial trauma, or they may occur in isolation. b. Always assess the patient's mouth following a facial injury. c. In an unconscious patient with missing teeth that cannot be located: i. Assume that the teeth are in the airway. ii. Direct visualization with a laryngoscope may be necessary.

Foreign bodies in the ear

a. Most common in the pediatric population. i. The majority of objects are solid; however, organic matter is also possible. b. Assessment should determine the nature of the object and the urgency of treatment. i. Limited to visual clues, such as: (a) Bleeding (b) Redness (c) Inflammation (d) Symptoms associated with infection. c. Serious symptoms or discomfort, as well as inserted objects that may cause harm or damage if untreated, must be considered an emergency.

Maxillary fractures

a. Most commonly associated with mechanisms that produce massive blunt facial trauma. b. They produce: i. Massive facial swelling ii. Instability of the midfacial bones iii. Malocclusion iv. Elongated appearance of the patient's face c. Le Fort fractures are classified into three categories: i. Le Fort I fracture (a) Horizontal fracture of the maxilla (b) Separates the hard palate and inferior maxilla from the rest of the skull ii. Le Fort II fracture (a) Fracture with a pyramidal shape (b) Involves the nasal bone and inferior maxilla iii. Le Fort III fracture (a) Fracture of all midfacial bones (b) Separates the midface from the cranium d. Look for CSF leaking from the patient's nose i. May indicate an open skull fracture

Blunt eye injuries

a. Range of injuries from swelling and ecchymosis to rupture of the globe b. Hyphema: bleeding into the anterior chamber of the eye that obscures vision i. Eight-ball hyphema is a dark-colored clot that covers the entire anterior chamber. ii. An acute injury leads to the collection of bright red blood. iii. Dark blood suggests a nonacute injury. c. Visualization of the hyphema: shining a penlight from an angle through the anterior chamber i. Light will exaggerate the height of the blood in the chamber, allowing it to be differentiated from blood on the corneal surface. ii. A patient will report: (a) Photophobia (b) Pain (c) Blurred vision (d) Drowsiness iii. If a patient has an altered level of consciousness, suspect and treat for a head injury. d. Retinal detachment: separation of the inner layers of the retina from the underlying choroid i. Painless condition (a) Produces flashing lights, specks, or floaters in the field of vision (b) Produces a cloud or shade over the patient's vision ii. Requires urgent medical attention e. Central retinal artery occlusion i. Causes ischemia and necrosis of the retina if blood flow is not restored quickly ii. Can cause permanent loss of vision if blood flow is not restored quickly iii. Patients (a) Complain of sudden, painless loss of vision (b) Are commonly in their early 60s (c) Are more likely to be male than female

Injuries to the larynx, trachea, and esophagus

a. These injuries may result if the structures of the anterior part of the neck are crushed against the cervical spine or if they are penetrated by an object. b. Injuries may not be obvious. c. Significant injuries to the larynx or trachea pose an immediate risk of airway compromise. d. Esophageal perforation can result in mediastinitis. i. Inflammation of the mediastinum is often due to leakage of gastric contents into the thoracic cavity. ii. Mediastinitis has a very high mortality rate. e. Concomitant maxillofacial fractures can make bag-mask ventilation difficult. f. ET intubation may also be challenging, if not impossible. g. A surgical or needle cricothyrotomy may be necessary.

Mandibular fractures and dislocations

a. Typically result from massive blunt force trauma to the lower third of the face b. May be fractured in more than one place i. Unstable to palpation c. Suspect in patients with a history of blunt force trauma to the lower third of the face who present with: i. Dental malocclusion ii. Numbness of the chin iii. Inability to open the mouth d. Other findings: i. Swelling and ecchymosis over the fracture site ii. Partially or completely avulsed teeth e. Eliciting tenderness by palpating specific locations on the mandible i. Point tenderness and pain on motion can identify injuries that patients might not report. f. Temporomandibular joint (TMJ) dislocations i. Most often the result of exaggerated yawning or widely opening the mouth. ii. The patient commonly feels a pop and then cannot close his or her mouth.