Chapter 33 : FACE AND NECK TRAUMA EMS 363 By: Dr.Deepti Patil

Chapter 33 : FACE AND NECK TRAUMA

EMS 363 By: Dr.Deepti Patil

THE FACIAL BONES

• 14 facial bones

• Two major nerves provide control: Trigeminal nerve

• Ophthalmic nerve• Maxillary nerve • Mandibular nerve

Facial nerve

THE FACIAL BONES

• OrbitsCone-shaped fossaEnclose and protect the eyes

THE FACIAL BONES

• NoseNasal septum separates

the nostrils External portion is

formed of cartilagePara nasal sinuses

• Hollowed bone lined with membranes

THE FACIAL BONES

• MandibleMovable bone forming the lower jaw

• Temporomandibular joint (TMJ) Allows movement of the mandible

THE FACIAL BONES

THE EYE

• Globe: spherical structure housed within the orbit

• Oculomotor nerve Innervates the muscles

that cause motion

• Optic nerveProvides the sense of

vision

THE EYE

• Structures of the eye include:ScleraCornea Conjunctiva Iris Pupil LensRetina

THE EAR

• Divided into three anatomic partsExternal earMiddle ear Inner ear

THE TEETH

• 32 permanent teeth• Crown: top portion of the tooth• Pulp cavity fills the center of the tooth and contains:

Blood vesselsNervesSpecialized connective tissue

THE MOUTH

• Hypoglossal nerve(12th CN)Provides motor function to tongue

• Glossopharyngeal nerve (9th CNProvides taste sensation

• Mandibular branch of trigeminal nerve(5th CN)Provides motor innervations

• Facial nerve(7th CN)Provides taste and sensations

THE ANTERIOR REGION OF THE NECK

• Structures:Thyroid and cricoid

cartilageTracheaMuscles and nerves

• Major blood vessels: Carotid arteries Jugular veins

SCENE SIZE-UP

• Determine the number of patients.• Consider need for additional resources.• Evaluate the mechanism of injury (MOI).

PRIMARY 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.

• Airway and breathingSuction as needed. Correct airway patency.Assess the patient’s breathing.

PRIMARY ASSESSMENT

• CirculationPalpate the pulse. Inspect the skin. Control significant bleeding.

• Transport decision

The following require immediate transport:• Poor initial general impression• Altered level of consciousness• Dyspnoea• Abnormal vital signs• Shock• Severe pain• Signs of shock

HISTORY TAKING

• Ask about the injury.Record information on the patient care record.

SECONDARY ASSESSMENT

• Assess the respiratory system. Listen for air movement and breath sounds. Assess for asymmetric chest wall movement.

• Assess the neurologic system.Level of consciousnessPupil size and reactivityMotor responseSensory response

SECONDARY ASSESSMENT

• Assess the musculoskeletal system. Look for DCAP-BTLS. Assess the chest, abdomen, and extremities. Assess the posterior torso.

• Assess all anatomic regions.• Record pulse, motor, and sensory function. • Reassess the vital signs.

REASSESSMENT

• Obtain and evaluate vital signs. • Check interventions.

• Repeat the primary assessment.• Documentation should include:

Description of the MOIPosition in which you found the patientLocation and description of injuriesAccurate account of treatment

PATHOPHYSIOLOGY OF FACE INJURIES

• Soft-tissue injuries Impaled objects present risk of airway compromise. Massive oropharyngeal bleeding can result in:

• Airway obstruction• Aspiration

• Maxillofacial fracturesOccur when facial bones absorb strong impactWhen assessing, protect the cervical spine.First clue: ecchymosis


• Nasal fractures Characterized by:

• Swelling• Tenderness• Crepitus

• Mandibular fractures and dislocationsSuspect in patients with blunt force trauma to lower third of

face, presenting with: • Dental malocclusion • Numbness of the chin• Inability to open the mouth


• Maxillary fractures : characterized by• Massive facial swelling• Malocclusion• Elongated appearance of the face

• Orbital fractures : characterized by• Massive nasal discharge • Impaired vision • Paralysis of upward gaze

ASSESSMENT OF FACE INJURIES

• Assessment is primarily clinical.

• Pay attention to:Swelling and deformity InstabilityBlood loss

• Evaluate the cranial nerve function.

• Visually inspect the oropharynx for signs of posterior epistaxis.

MANAGEMENT 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.• Assess breathing and intervene appropriately.• Perform ET intubation.

MANAGEMENT OF FACE INJURIES

• Soft-tissue injuriesControl bleeding with direct pressure; apply sterile

dressings. Leave impaled objects in the face unless they pose a threat

to the airway 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.

PATHOPHYSIOLOGY OF EYE INJURIES

• Foreign bodies, impaled objectsForeign objects can

produce irritation.

• Conjunctivitis: inflamed and red conjunctiva

• Eye produces tears.


• Blunt eye injuries

Hyphema: bleeding into anterior chamber that obscures vision


• Burns of the eyeChemical burns require immediate emergency care.

• Flush with water or a sterile saline solution.

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

ASSESSMENT OF EYE INJURIES

• Note the MOI. • Ensure a patent airway.• Control any external bleeding. • If appropriate, perform a rapid exam.• Symptoms of serious ocular injury:

Visual lossDouble vision Severe eye pain A foreign body sensation

ASSESSMENT OF EYE INJURIES

• During physical examination, evaluate:Orbital edge: ecchymosis, swelling, lacerations, tendernessEyelids: ecchymosis, swelling, lacerationsCorneas: foreign bodiesConjunctivae: redness, pus, inflammation, foreign bodiesPupils: size, shape, equality, reaction to lightEye movements: paralysis of gaze or disco ordination

between eyesVisual acuity: ask patient to read a newspaper

MANAGEMENT OF EYE INJURIES

• Lacerations and blunt traumaWhen 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.


• Lacerations and blunt trauma (cont’d)

If hyphema or rupture of the globe is suspected, take spinal motion restriction precautions.

Elevate the head app.40 degree to decrease intraocular pressure.

If the globe is displaced out of its socket, do not attempt to manipulate or reposition it.

Courtesy of AAOS


• Foreign bodies, impaled objectsDo not remove a foreign body impaled in the globe.Stabilize object. Promptly transport the patient.

• 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.


• Burns caused by ultraviolet lightCover with a sterile, moist pad and eye shield. Apply cool compresses if patient is in distress. Place the patient in a supine position.

• Chemical burns Immediately irrigate with water or saline solution. Avoid contaminated water getting into unaffected eye. Irrigate for at least 5 minutes.


Courtesy of AAOS Courtesy of AAOS

Courtesy of AAOS Courtesy of AAOS

PATHOPHYSIOLOGY OF EAR INJURIES

• Soft-tissue injuriesPinna has a poor blood supply.

• Tends to heal poorly • Healing is often complicated by infection.

• Ruptured eardrumSigns and symptoms include:

• Loss of hearing • Blood drainage from the ear

Typically heals spontaneously

ASSESSMENT AND MANAGEMENT OF EAR INJURIES

• Ensure breathing adequacy. • If MOI suggests spinal injury, apply full spinal motion

restriction precautions.• 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

• 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

• Soft-tissue injuriesPlace the responsive patient with severe oral bleeding

leaning forward. Impaled objects can result in profuse bleeding.May be associated with mechanisms that cause severe

maxillofacial traumaAlways assess the mouth following facial injury.

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.

• 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

• Soft-tissue injuriesBlunt trauma often results in:

• Swelling and edema• Injury to the cervical spine

Be prepared to initiate aggressive management.

Primary threats from penetrating trauma: • Massive hemorrhage • Airway compromise

Air embolisms are associated with open neck injuries.


• Soft-tissue injuries (cont’d) Impaled objects can

present life-threatening problems.

• Do not remove impaled objects unless they interfere with the airway.


• Injuries to larynx, trachea, and esophagusSignificant 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

• Common signs:BruisingRedness to the overlying skinPalpable tenderness

• 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

• 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.

PATHOPHYSIOLOGY OF SPINE TRAUMA

• Sprain: stretching or tearing of ligamentsProvide cervical spine stabilization.

• Strain: stretching or tearing of muscle or tendonCervical precautions should be taken.

ASSESSMENT OF SPINE TRAUMA

• Transport to the ED for radiologic studies.

• If the patient is symptomatic with pain, maintain spinal stabilization.

• 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 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.

• If your examination reveals no obvious MOI, consider treatment for muscular strain. Rest, ice, elevationSoft collar

SUMMARY

• Head and face trauma most often result from direct trauma or rapid deceleration.

• 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.

SUMMARY

• 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.

• Never remove impaled objects from the eye.

• Chemical burns to the eye should be treated with gentle irrigation.

SUMMARY

• 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.

• 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.

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Chapter 33 : FACE AND NECK TRAUMA EMS 363 By: Dr.Deepti Patil