Ch. 27: Face and Neck Injuries

5. Explain emergency medical care of a patient with softtissue wounds of the face and neck. (pp 955-956)

(key points that are not obvious are included here) Scene size up: -pts may cough blood at you -Consider how the MOI produced the injuries expected. common include car crashes, trauma, assault Primary -control bleeding and airway -assess LOC and need for airway adjunct -place an occlusive dressing on a penetrating trauma wound -provide O2 -provide ventilation via BVM if needed -do not splint or immobilize a chest wall -use nonrebreathing masks for face injuries assess pulse, skin condition, color, temp, and capillary refill -consider ALS backup for long transport times -Bleeding from major vessels of the throat can have a serious impact on the patient's airway. -Treatment is directed at quickly addressing life threats and providing rapid transport to the closest appropriate hospital. -restoration of eye injury may need to be accomplished within 30 minutes to prevent blindness History -obtained after life threats are managed -SAMPLE Secondary -may not have time for this -assess DCAPBTLS over whole body, then a focused assessment -Ask yourself the following questions: Do the facial bones seem to be in alignment? Does the nasal bone seem to deviate from the midline? Note any variations from the normal facial examination; is there any facial drooping? Does one eye appear to be lower than the other? If so, this is an indication of an orbital fracture. Does the mandible appear to deviate toward one side or the other? -stabilize impaled objects -assess underlying systems: neurologic, sensory, respiratory, circulatory -Quickly assess the patient's visual acuity by gently covering one eye and holding fingers up at arm's length in front of the open eye. -assess pupils for regularity -It is recommended that you always assess the patient's first blood pressure manually with a sphygmomanometer (blood pressure cuff) and stethoscope. -determine pulse, respirations, BP, and oxygen saturation Reassessment -repeat primary assess -recheck vitals -maintain airway -documentation: MOI, pt's position when found, extrication details, estimated blood loss, all injuries

3. Discuss the different types of facial injuries and patient care considerations related to each one. (pp 950-951)

-Because the face and neck are highly vascularized, swelling can be very severe as compared to other soft tissue injuries. -A blunt injury that does not break the skin may cause a break in a blood vessel wall, leading to a hematoma. -dental and mandible fractures -Mandible fractures are second only to nasal fractures in frequency.

12. Explain the emergency medical care of a patient with an upper airway injury caused by blunt trauma. (pp 970-971)

-If you feel leakage when you palpate the neck, maintain the airway as best you can and provide immediate transport. -If you feel leakage when you palpate the neck, maintain the airway as best you can and provide immediate transport.

9. Explain the emergency medical care of a patient with injuries of the ear, including lacerations and foreign body insertions. (pp 967-969)

-In the case of an ear avulsion, wrap the avulsed part in a moist, sterile dressing and put it in a plastic bag labeled with the patient's name. -Keep the avulsed part cool and transport to the hospital with the patient -don't try to remove objects, bc this could push them further in -place a padded dressing between the back of ear and scalp before wrapping a dressing around the ear/head

8. Explain emergency medical care of a patient with injuries of the nose. (pp 965-967)

-Posterior nosebleeds are more severe and often cause blood to drain into the patient's throat, causing nausea and vomiting. -turbinates: Layers of bone within the nasal cavity. Control bleeding from abrasions and lacerations to the nose by applying a sterile dressing. -If the patient is bleeding heavily from the nose, consider cervical spine injury. -Do not move the patient if the airway can be managed in the patient's present position. -For a non-trauma patient who is bleeding from the nose, place the patient in a sitting position, leaning forward, and pinch his or her nostrils together.

7. Describe the three different causes of a burn injury to the eye and patient management considerations related to each one. (pp 959-961)

-chemical: irrigate eye for 20 minutes -thermal: Be sure to cover both eyes with a sterile dressing moistened with sterile saline. You may apply eye shields over the dressing. -thermal: Ease the pain by covering each eye with a sterile, moist pad and an eye shield.

13. Explain the emergency medical care of the patient with a penetrating injury to the neck; include how to control regular and life-threatening bleeding. (pp 971-972)

-penetrating injuries in the neck cause profuse bleeding from the great vessels of the neck -beware of patient bleeding out, or an air embolism -a large amount of air in the right side of the heart leads to cardiac arrest -injury to the larynx can cause injury to the posterior cervical spine. suspect this injury when there is laryngeal trauma

4. Explain the emergency care of a patient who has sustained face and neck injuries; include assessment of the patient, review of signs and symptoms, and management of care. (pp 950-956)

-same as other soft-tissue injuries of the body -first step is open and clear airway -suctioning may be needed for bleeding in the throat -control bleeding with direct pressure -secure dressings with gauze -When an injury exposes the brain, eye, or other structures, cover the exposed parts with a moist, sterile dressing to protect them from further damage. -For injuries in which the skin is not broken, apply ice locally to help control the swelling of bruised tissues. -If you find portions of avulsed skin that have become separated, wrap them in a sterile dressing, place them in a plastic bag, and keep them cool. -if skin flaps are still attached, put them back as normal as possible, and hold them in place with dry dressing.

Skills Objectives 1. Demonstrate the removal of a foreign object from under a patient's upper eyelid. (pp 956-958, Skill Drill 27-1)

1. Have the patient look down, then grasp the upper lashes and gently pull the lid away from the eye 2. Place a cotton- tipped applicator on the outer surface of the upper lid 3. pull the lid forward and up, folding it back over the applicator 4. Gently remove the foreign object from the eyelid with a moistened, sterile, cotton-tipped applicator

5. Demonstrate how to control bleeding from a neck injury. (pp 971-972, Skill Drill 27-3)

1. if necessary, apply direct pressure to the bleeding site using a gloved fingertip to control bleeding. 2. apply a sterile occlusive dressing to ensure that air does not enter a vein or artery

2. Demonstrate the stabilization of a foreign object that has been impaled in a patient's eye. (pp 959-960, Skill Drill 27-2)

1. to prepare a doughnut ring, wrap a 2- inch roll around your fingers and thumb 7 or 8 times. Adjust the diameter by spreading your fingers or squeezing them together 2. remove the gauze from your hand and wrap the remainder of the gauze roll radially around the ring that you have created 3. work around the entire ring to form a doughnut 4. place the dressing over the eye and impaled object to hold the impaled object in place and then secure it with a roller bandage

11. Explain the emergency medical care of the patient with dental and cheek injuries; include how to deal with an avulsed tooth. (p 970)

Dental Apply direct pressure to stop the bleeding. To keep the airway patent, perform suctioning if needed. -When dealing with an avulsed tooth, handle it by its crown and not by the root. -Bring the tooth to the emergency department, placing it in a special tooth storage solution (if available in your supplies), or in cold milk or sterile saline. -implantation of the avulsed tooth is recommended between 20 mins to 1 hour after the trauma Cheek -If you are unable to control the bleeding and it is compromising the patient's airway, consider removing the impaled object if possible and provide direct pressure on the inside and outside of the cheek. -The amount of bandaging should not be so overwhelming that it occludes the mouth and makes it difficult for the patient to breathe.

2. Describe the factors that may cause the obstruction of the upper airway following a facial injury. (pp 950-951)

Factors: -bleeding from facial injury -direct injuries to the nose and mouth, larynx, or trachea -swelling that accompanies these injuries -When the patient's head is turned to the side, as often is done when the patient has an altered level of consciousness or is unconscious -Possible injuries to the brain and/or cervical spine that may be associated with facial injuries

6. Explain the emergency medical care of a patient with an eye injury based on the following scenarios: foreign object, impaled object, burns, lacerations, blunt trauma, closed head injuries, and blast injuries. (pp 956-965)

Foreign objects -Conjunctivitis is when the conjunctiva becomes inflamed and red, and the eye begins to produce tears in an attempt to flush out a foreign object. -If a small foreign object is lying on the surface of the patient's eye, use a normal saline solution to irrigate the eye gently. -flush from inner corner to outer corner -follow the first two skill drills in the skills objectives -When you see or suspect an impaled object in the eye, bandage both eyes with soft, bulky dressings to prevent further injury to the affected eye. - this prevents sympthetic mvmt of the injured eye moving as the normal eye moves burns -include chemical, thermal, and light -chemical: irrigate eye for 20 minutes -thermal: Be sure to cover both eyes with a sterile dressing moistened with sterile saline. You may apply eye shields over the dressing. -thermal: Ease the pain by covering each eye with a sterile, moist pad and an eye shield. lacerations -never press on or manipulate injured eye -apply a moist, sterile dressing on eyeball if it is exposed -Cover the injured eye with a protective metal eye shield, cup, or sterile dressing. Apply soft dressings to both eyes and provide prompt transport to the hospital. Blunt trauma -protect with shield to prevent further mvmt -cover eye Eye injuries from head injury -For an unconscious patient, remember to keep the eyelids closed. -Cover the lids with moist gauze, or hold them closed with clear tape. Blast injuries -if a foreign body is in the globe, put a cup or similar item over the object to stabilize it -do not attempt to open a swollen eyelid or an eyelid with a hematoma impaled object: 1. never exert pressure or manipulate the globe in any way 2. if part of the eyeball is exposed, gently apply a moist, sterile dressing to prevent drying 3. cover the injured eye with a protective metal eye shield, cup, or sterile dressing. Apply soft dressings to both eyes, and provide prompt transport

eye anatomy

The eyeball, or globe, keeps its shape as a result of the pressure of the fluid contained within its two chambers. The clear, jellylike fluid near the back of the eye is called the vitreous humor. In front of the lens is a clear fluid called the aqueous humor, named for its watery appearance. conjunctiva The delicate membrane that lines the eyelids and covers the exposed surface of the eye. lacrimal glands The glands that produce fluids to keep the eye moist; also called tear glands. iris The muscle and surrounding tissue behind the cornea that dilate and constrict the pupil, regulating the amount of light that enters the eye; pigment in this tissue gives the eye its color. Anisocoria is a condition where pupils are not equal.

1. Describe the anatomy and physiology of the head, face, and neck; include major structures and specific important landmarks of which EMTs must be aware. (pp 947-950)

The forehead is called the frontal region. Just anterior to the ear, in the temporal region, you can feel the pulse of the superficial temporal artery. occiput= most posterior portion parietal = between occiput and frontal Face has 6 major bones: nasal bone, 2 maxillae, 2 zygomatic bones, and the mandible Only the proximal third of the nose— the bridge—is formed by bone. The remaining two-thirds are composed of cartilage. Pinna= external part of ear. The mastoid process is a prominent bony mass at the base of the skull 1 inch posterior to the external opening of the ear. temporomandibular joint The joint formed where the mandible and cranium meet, just in front of the ear. The Adam's apple is the upper part of the larynx, formed by the thyroid cartilage. The other portion of the larynx is the cricoid cartilage, which is below the thyroid cartilage and is more difficult to palpate. Sternocleidomastoid muscles lie lateral to the carotid and jugular vessels. They insert at the sternum.

10. Explain the physical findings and emergency care of a patient with a facial fracture. (pp 969-970)

clues to the possibility of fracture include: -Bleeding in the mouth Inability to swallow or talk -Absent or loose teeth -Loose or movable bone fragments -Patients may report that "it doesn't feel right" when they close their jaw, signaling an irregularity of bite. treatment: -Remove any loose dentures or dental bridges to protect against airway obstruction. -check for airway obstruction