EMT: Chapter 27 [face and neck injuries]

how to remove a foreign object from under the upper eyelid:

*if irrigation doesn't work; only if foreign object stuck to eyelid, not cornea 1. have the patient look down; then grasp lashes and pull lid away from eye 2. place a cotton-tipped applicator on the outer surface of upper lid 3. pull lid forward and up over the applicator 4. remove the foreign object from the eyelid with a moistened cotton-tipped applicator

blunt trauma to the eye

- "black eye" (bleeding into tissue around orbit tissue) - damaged orbit - hyphema: bleeding into the anterior chamber of the eye that obscures the iris - fracture of orbit bones (-> double vision) - retinal detachment (-> flashing lights, specks, cloudiness in patient's vision)

nose injuries

- anterior nosebleed: arises from septum, bleeds slowly, resolves quickly - posterior nosebleed: more severe, bleeds into throat non-trauma patient: place patient in sitting position, lean them forward, and pinch nostrils together CSF present in blood = characteristic of cervical spine injury (blood surrounded by lighter ring of fluid)

signs of facial fracture

- bleeding to the mouth - inability to swallow/talk - absent or loose teeth - loose or movable bone fragments - irregular bite *remove loose dentures/dental bridges, check for airway obstruction

types of eye injuries

- blunt/penetrating injuries (swollen, lacerated eyelids) - bleeding after irritation/injury (bright-red conjunctiva) - damaged cornea (dry appearance)

assessment

- control bleeding > occlusive dressing for penetrating trauma > do not splint chest (contraindication) - ABCs > still use mask despite facial injuries - AVPU - DCAP-BTLS - transport any significant MOIs promptly (suspect spinal/brain injuries) - transport eye injuries to eye care specialty centers

eye out-of-socket

- do not reposition - for both eyes: cover and stabilize with moist dressing to - have pt lie supine

reassessment

- every 5 minutes - immobilization OR sitting position documentation: - describe MOI and pts position - describe any methods used to remove pt - estimate amount of blood loss - detail all injuries involving head/neck

emergency medical care

- frequent suctioning - turn backboard (if applicable) to side to allow blood/vomitus to drain out - control bleeding with direct pressure - use roller gauze wrapped around head to hold dressing in place - apply ice to swelling - check inside mouth for bleeding - keep detached skin in a sterile, cool plastic bag (never place tissues on ice) - keep avulsed skin as close as possible to the original position and hold in place

blast injuries

- make sure scene is safe - secure foreign objects and place cup etc. over the area - instruct patients verbally on what actions are taking place around them - do not force eye open if severe swelling/hematoma to eyelid

major face bones

- nasal bone - x2 upper jaw (maxillae) - jaw bone (mandible) - x2 cheek bones (zygomas)

eye lacerations

- never exert pressure on or manipulate the globe - gently apply exposed eyeball with moist, sterile dressing - cover injured eye with a protective metal shield

contact lenses

- never remove if eye has been injured UNLESS in case of chemical burn - if removal necessary, place 1-2 drops saline in eye and gently pinch the lens to lift it off surface of eye - place contacts in sterile saline solution

important portions of ear

- pinna: external outer ear - ear lobes - tragus (fleshy bulbe)

neck landmarks

- spinal cord (cervical vertebra) - Adam's apple: upper larynx (thyroid cartilage) - cricoid cartilage: lower larynx -- more difficult to palpate - thyroid glands (either side of lower larynx) -- can palpate if enlarged - carotid arteries

scene size-up

- standard precautions (eye protection, face mask, several pairs of gloves) - number pts - MOI indicators - how did MOI produce injuries expected? (MVC, sports, falls, penetrating/blunt trauma) - what type of MVC crash (worse if rollover) or sports?

how to control bleeding from a neck injury:

1. apply direct pressure to bleeding site 2. apply a sterile occlusive dressing to ensure air does not enter

how to stabilize a foreign object impaled in the eye:

1. prepare a doughnut ring by wrapping a 2-inch roll around your fingers about 7-8 times (adjust diameter by spreading out fingers) 2. remove gauze and wrap rest of roll radially around ring you have created 3. work around entire ring to form a doughnut 4. put dressing over eye and impaled object to hold it in place; secure with a roller bandage (over both eyes -- prevents movement of one eye from causing both to move)

Abnormal variations in pupil size and reaction would MOST likely be observed in a patient with:

a brain injury

What is an air embolism?

a clinical situation in which a vein is punctured and air is sucked into the heart

What is a hematoma?

a collection of blood within the tissues

A 30-year-old female presents with redness, inflammation, and pain to her left eye. During your assessment, you note that she is having difficulty keeping her eyes open. You should suspect that she is experiencing:

a corneal abrasion

When transporting a patient with a facial injury, it is MOST important to be as descriptive as possible with the hospital regarding the patient's injury because:

a specialist may be needed to manage the injury

What is the function of the sternocleidomastoid muscle?

allows movement of the head

An 82-year-old man experienced a minor facial injury when he tripped and fell. He is conscious and alert and complains of slight pain to his cheekbones. His medical history includes hypertension, blood clots in his legs, hypothyroidism, and type 2 diabetes. During your assessment, it is important to remember that:

any patient who falls should have their spine immobilized

You are dispatched to a convenience store where the clerk sustained a laceration to the side of his neck during a robbery attempt. During your assessment, you note bright red blood spurting from the laceration. You should:

apply direct pressure above and below the wound

A young female was involved in a motor vehicle crash. She complains of pain to her left eye, which appears to have a piece of glass impaled in it. Further assessment reveals a large laceration to her left forearm with active venous bleeding. As your partner manually stabilizes the patient's head, you should:

apply direct pressure to her arm wound

which of the following statements is NOT true regarding the treatment of bleeding from a neck injury?

apply firm pressure to the carotid artery to reduce the amount of bleeding

A 52-year-old unrestrained female struck the steering wheel with her face when her truck collided with another vehicle. She has obvious swelling to her face and several dislodged teeth. A visual exam of her mouth reveals minimal bleeding. She is conscious and alert with a blood pressure of 130/80 mm Hg, a pulse of 110 beats/min, and respirations of 22 breaths/min with adequate depth. You should:

apply supplemental O2, immobilize her spine, attempt to locate the dislodged teeth, suction as needed, and transport

Which of the following fractures is associated with bruising around the ears and blood coming from the nose?

basilar skull fracture

lens

behind iris; focuses images on retina

The term "hyphema" is defined as:

blood in the anterior chamber of the eye

Which of the following statements regarding scalp lacerations is correct?

blood loss from a scalp laceration may result in hypovolemic shock, especially in children

You are assessing a patient who was hit in the face by a baseball bat. There are multiple contusions on his face, and he reports double vision. His left eye does not track with his right eye. What should you suspect?

blow-out fracture

Unequal pupils most likely indicate what type of injury?

brain

eustachian tube

branch of the internal auditory canal that connects the middle ear to the oropharynx

Which of the following findings would be LEAST suggestive of a head injury?

briskly constricting pupils when exposed to light

penetrating injuries to neck

can cause exsanguination or air embolism (if hits carotid/jugular veins) -> cardiac arrest

A 50-year-old male was splashed in the eyes with radiator fluid when he was working on his car. During your assessment, he tells you that he wears soft contact lenses. You should:

carefully remove the contact lenses and then irrigate his eyes with saline

secondary assessment: eyes

check for visual acuity in both eyes by covering one and then testing ability to see fingers note discoloration, bleeding, redness, asymmetry check reactivity of pupils to light and if they're equal sizes - can pt follow finger from side to side and up and down? - can pt read normal print? - does pt report blurry vision? - is there a new sensitivity to light

cornea

clear front of the eye which allows light to enter the eye

A 39-year-old female experienced a severe closed head injury. She is unconscious with her eyes slightly open; her pupils are bilaterally dilated and slow to react. In addition to managing problems with airway, breathing, and circulation, you should:

close her eyes and cover them with a moist dressing

the _______________ connects the cricoid cartilage and the thyroid cartilage.

cricothyroid membrane

Bleeding from soft-tissue injuries to the face is MOST effectively controlled with:

direct pressure using dry, sterile dressings

the middle ear is connected to the nasal cavity by the:

eustachian tube

orbit

eye socket composed of frontal skull bone, zygoma, maxilla and nasal bone

thermal eye burns

eyelids frequently burned in a fire cover both eyes with a moistened sterile dressing provide immediate transport

The maxilla and zygoma are components of the ________.

face

You are assessing a 59-year-old male who complains of a headache and note that his pupils are asymmetrical. He is conscious and alert. When obtaining his medical history, it is MOST pertinent to ask him if he:

has a history of eye surgeries

The skin and underlying tissues of the face:

have a rich blood supply and bleed profusely

A factory worker was splashed in the eyes with a strong acid chemical. He complains of intense pain and blurred vision. If you do not have sterile saline or water, you should:

irrigate both eyes continuously for 20 minutes with plain water

A 22-year-old male was walking on the beach and had sand blown into his eyes. He complains of pain and decreased vision to his right eye. Treatment should include:

irrigating his right eye laterally

The cricoid cartilage:

is the only complete circular cartilage of the trachea

Which of the following statements regarding the vitreous humor is correct?

it is a clear, jellylike fluid near the back of the eye that cannot be replaced if it is lost

When a light is shone into the pupil:

it should become smaller in size

The superficial temporal artery can be palpated:

just anterior to the tragus

Following direct trauma to the upper part of the anterior neck, a young male presents with labored breathing, loss of voice, and subcutaneous emphysema in the soft tissues around his neck. You should suspect a(n):

laryngeal fracture

turbinates

layers of bone within each nasal cavity covered with a moist lining that humidifies air

retina

light-sensitive back of globe that is nourished by choroid (layer of blood vessels)

The upper jawbones are called the:

maxillae

soft-tissue injuries

may be more severe since face/neck are extremely vascular ex. hematoma ex. avulsion

conjunctiva

membrane which covers inner surface of eyelids and the exposed surface of the eye itself

sternocleidomastoid muscles

muscles on either side of the neck that allow movement of the head

What is the most common type of facial fracture?

nasal

Which area of the body are you palpating if you feel subcutaneous emphysema?

neck

ear injuries

never try to manipulate foreign body lodged in ear clear fluid coming out can indicated base skull fracture

cranium

occiput: posterior temples/temporal regions: lateral (feel pulse here of superficial temporal artery) parietal regions: between temporal and occipital regions frontal region: forehead foramen magnum: large opening at the base of the skull connecting brain to spinal cord

retinal detachment

occurs if retina detaches from underlying choroid and sclera, causing partial -> full blindness

Facial injuries should be identified and treated as soon as possible because:

of the risk for airway problems

A 44-year-old male sustained a laceration to his left ear during a minor car accident. Your assessment reveals minimal bleeding. Appropriate care for this injury includes:

padding between the ear and the scalp

mandible fractures

result from MVCs/assaults signs: - misaligned teeth - chin numbness - inability to open the mouth

The white portion of the eye is called the:

sclera

blunt injuries to neck

signs: - depressed region - loss of voice - difficulty swallowing - airway obstruction - subcutaneous emphysema feel for leakage from trachea as you palpate neck ALS/spinal immobilization may be necessary

eye injuries following head injury

signs: - one pupil larger - eyes not moving together or pointing in different directions - failure of eyes to follow movement of finger - bleeding under conjunctiva - protrusion of one eye *close eyelids in an unconscious patient to prevent drying of ocular tissue (if impossible cover w moist gauze)

A 30-year-old female was assaulted by a gang as she was leaving a nightclub. She has massive facial trauma and slow, gurgling respirations. As your partner manually stabilizes her head, you should:

suction her oropharynx for 15 seconds

The Adam's apple is:

the upper part of the larynx that is formed by the thyroid cartilage

Which of the following statements regarding anterior nosebleeds is correct?

they usually originate from the septum area and bleed slowly

optic nerve

transmit nerve impulses which brain interprets as vision

A 4-year-old female has a peanut lodged in the external auditory canal of her right ear. You should:

transport her to the ED

You are transporting an immobilized patient with severe facial trauma. As you are preparing to give your radio report to the hospital, the patient begins vomiting large amounts of blood. You should:

turn the backboard onto its side

When caring for a patient with an open facial injury, the AEMT must:

wear gloves and facial protection

which of the following is NOT a sign or symptom of a laryngeal injury?

wheezing

possible causes of unequal pupils:

- OTC eye drops - inhalers in eyes - brain injury - nerve disease - glaucoma - meningitis

The mastoid process is located approximately:

1" posterior to the external opening of the ear

when a patient has a chemical burn to the eye, you should irrigate the eye for at least 5 minutes; however, if the burn was caused by an alkali or strong acid, you should irrigate for:

20 minutes

When performing a full body scan, you should assess for ________.

DCAP-BTLS

history taking

SAMPLE (via family or pt) to discover cause of injuries

pupil

allows light to move to the back of the eye unequal sizes may indicate serious injury or brain illness

Which of the following is or are found in the middle ear?

anvil, hammer and stirrup

Retinal injuries that are caused by exposure to extremely bright light:

are not typically painful but may result in permanent damage to visio

dental injuries

assess patient's mouth following a facial injury teeth fragments can become airway obstructions and should be removed - suction airway and apply direct pressure to bleeding handle avulsed teeth by their crown, not the root - bring to ED via direct tooth storage

A young female experienced a laceration to her left eyeball from flying glass when her boyfriend broke a soda bottle against a wall. There is moderate bleeding and the patient states that she cannot see out of the injured eye. You should:

avoid applying pressure to the globe when you are covering her eye

what injuries can cause airway obstruction:

bleeding from facial injuries -> clotting in airway direct injuries to nose/mouth or larynx/trachea - significant bleeding - suctioning necessary - loosened death/dentures may have been swallowed swelling to soft tissues in the neck - ex. rupture of great vessels -> bleeding/pressure possible injuries to the brain/cervical spine

which of the following is NOT a sign of a possible facial fracture?

bleeding from the forehead

What is hyphema?

bleeding into the anterior chamber of the eye

laryngeal injuries

can be caused by penetration (stabbing, etc.) -> airway compromise, swelling, aspiration of blood signs: - respiratory distress - hoarseness - pain - difficulty swallowing - cyanosis - pale skin - sputum in wound - sub. emph - bruising, hematoma, bleeding around neck avoid use of rigid collars

you respond to a 71-year-old woman who is unresponsive. you try to get her to respond but have no success. her airway is open, and she is breathing at a rate of 14 breaths/min. you know you can check a pulse on the side of the neck. you know that the jugular veins and several nerves run through the neck next to the trachea. what structure are you trying to locate to take a pulse?

carotid arteries

iris

circular pigmented muscle behind the cornea

anisocoria

condition where pupils are not equal

The inner surface of the eyelids and the exposed surface of the eye itself are covered by a delicate membrane called the:

conjunctiva

temporomandibular joint

controls motion of mandible (jaw bone); lies in front of ear on either side of face

A 40-year-old male was in his woodworking shop when he felt a sudden, sharp pain in his left eye. Your assessment reveals a small splinter of wood embedded in his cornea. You should:

cover both eyes and transport to the hospital

secondary assessment: isolated injury

focus on: - chief complaint - isolated injury - body region affected

the brain connects to the spinal cord through a large opening at the base of the skull known as the:

foramen magnum

The eyeball itself is called the:

globe

Clinical findings associated with a laryngeal injury include:

hemoptysis, sub emph, cyanosis

You are treating a patient with significant bruising to her face and a broken nose. She is conscious, but her LOC is significantly altered and her breathing is labored. What should you do to manage this patient's airway?

insert an oropharyngeal airway

lacrimal (tear) glands

keeps conjunctiva moist

globe (eyeball)

keeps its shape as a result of pressure of fluid in its two chambers - clear fluid near back = vitreous humor - clear fluid in front of lens = aqueous humor

The conjunctiva are kept moist by fluid produced by the:

lacrimal glands

A 29-year-old male has an anterior nosebleed after he was accidentally elbowed in the nose. He is conscious and alert with adequate breathing. The MOST appropriate care for this patient includes:

leaning him forward and pinching his nostrils together

The lower jawbone is called the:

mandible

When assessing a patient with a mandibular fracture, you would MOST likely encounter:

misalignment of the teeth

light eye burns

not painful but cause permanent vision damage - UV light - prolonged exposure to sun lamp - snow blindness severe conjunctivitis often develops cover each eye with sterile moist pad and protect pt from further exposure to bright light

neck injuries

parts that are vulnerable to injuries: - upper airway - esophagus - carotid arteries/jugular veins - thyroid cartilage/Adam's apple - cricoid cartilage - upper trachea

secondary assessment

physical examination red flags: - swelling - bone deformity - contusions - discoloration - tenderness ask the following questions: - are facial bones aligned? - does nasal bone deviate from midline? - facial drooping? - is one eye lower than the other? - does mandible deviate toward one side? inspect how well bleeding is being controlled and if any foreign objects have been stabilized assess all underlying systems (neurologic, sensory, respiratory, circulatory) get baseline vitals to monitor progress (important in facial and throat injuries)

ear anatomy

pinna + external auditory canal -> tympanic membrane (eardrum) -> middle ear (3 small bones -- sense sound) -> inner ear (fine nerve endings)

mastoid process

prominent body mass 1 inch posterior to external ear opening

The opening in the center of the iris, which allows light to move to the back of the eye, is called the:

pupil

A 6-year-old female was riding her bicycle and struck a clothesline with her throat. She is breathing, but with obvious difficulty. Your assessment reveals a crackling sensation in the soft tissues of her neck and facial cyanosis. In addition to the appropriate airway management, the intervention that will MOST likely improve her chance of survival is:

rapidly transporting her to the hospital

cheek injuries

remove an impaled object if unable to control bleeding and if compromising breathing

maxillary fractures

result from blunt-force or high-energy impacts (ex. second collision in MVCs, blow from an object) signs: - facial swelling - instability of facial bones - misalignment of teeth

The optic nerve endings are located within the:

retina

Significant trauma to the face should increase the EMT's index of suspicion for a(n):

spinal column injury

Frequent reassessments of the patient with face or neck injuries are MOST important because:

such injuries can affect the respiratory system

The small, rounded, fleshy bulge immediately anterior to the ear canal is called the:

tragus

bridge

upper third of nose made of bone

chemical eye burns

usually caused by acid or alkaline solutions eye must be flushed out gently with an irrigation solution immediately - irrigation syringe, nasal cannula, pouring water in, large pan of water) - flush from inner toward outside corner - do this for 20 minutes continuously apply a clean dressing afterwards and transport

If your patient swallows blood following facial trauma, there is an increased risk of ________.

vomiting

conjunctivitis

when the conjunctiva becomes inflamed and red so the eye produces tears (due to presence of a foreign object) irrigate eye with saline solution (can use nasal cannula on top of nose to do this) transport just in case

In which instance would you consider removing an impaled object?

when the object is impaled in the cheek and compromises the airway

sclera

white of the eye; tough fibrous tissue that maintains globular shape