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 Orbits  Cone-shaped fossa  Enclose and protect the eyes

THE FACIAL BONES Nose  Nasal septum separates the nostrils  External portion is formed of cartilage  Para nasal sinuses Hollowed bone lined with membranes

THE FACIAL BONES Mandible  Movable 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 nerve  Provides the sense of vision

THE EYE Structures of the eye include:  Sclera  Cornea  Conjunctiva  Iris  Pupil  Lens  Retina

THE EAR Divided into three anatomic parts  External ear  Middle 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 vessels  Nerves  Specialized connective tissue

THE MOUTH Hypoglossal nerve(12 th CN)  Provides motor function to tongue Glossopharyngeal nerve (9 th CN  Provides taste sensation Mandibular branch of trigeminal nerve(5 th CN)  Provides motor innervations Facial nerve(7 th CN)  Provides taste and sensations

THE ANTERIOR REGION OF THE NECK Structures:  Thyroid and cricoid cartilage  Trachea  Muscles 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 breathing  Suction as needed.  Correct airway patency.  Assess the patient’s breathing.

PRIMARY ASSESSMENT Circulation  Palpate 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 consciousness  Pupil size and reactivity  Motor response  Sensory 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 MOI  Position in which you found the patient  Location and description of injuries  Accurate 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 fractures  Occur when facial bones absorb strong impact  When assessing, protect the cervical spine.  First clue: ecchymosis

PATHOPHYSIOLOGY OF FACE INJURIES Nasal fractures  Characterized by: Swelling Tenderness Crepitus Mandibular fractures and dislocations  Suspect in patients with blunt force trauma to lower third of face, presenting with: Dental malocclusion Numbness of the chin Inability to open the mouth

PATHOPHYSIOLOGY OF FACE INJURIES 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 Instability Blood 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 injuries  Control 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 objects  Foreign objects can produce irritation. Conjunctivitis: inflamed and red conjunctiva Eye produces tears.

PATHOPHYSIOLOGY OF EYE INJURIES Blunt eye injuries Hyphema: bleeding into anterior chamber that obscures vision

PATHOPHYSIOLOGY OF EYE INJURIES Burns of the eye  Chemical 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 loss Double vision Severe eye pain A foreign body sensation

ASSESSMENT OF EYE INJURIES During physical examination, evaluate: Orbital edge: ecchymosis, swelling, lacerations, tenderness Eyelids: ecchymosis, swelling, lacerations Corneas: foreign bodies Conjunctivae: redness, pus, inflammation, foreign bodies Pupils: size, shape, equality, reaction to light Eye movements: paralysis of gaze or disco ordination between eyes Visual acuity: ask patient to read a newspaper

MANAGEMENT OF EYE INJURIES Lacerations and blunt trauma  When 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.

MANAGEMENT OF EYE INJURIES 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

MANAGEMENT OF EYE INJURIES Foreign bodies, impaled objects  Do 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.

MANAGEMENT OF EYE INJURIES Burns caused by ultraviolet light  Cover 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.

MANAGEMENT OF EYE INJURIES Courtesy of AAOS

PATHOPHYSIOLOGY OF EAR INJURIES Soft-tissue injuries  Pinna has a poor blood supply. Tends to heal poorly Healing is often complicated by infection. Ruptured eardrum  Signs 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 injuries  Place 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 trauma  Always 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 injuries  Blunt 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.

PATHOPHYSIOLOGY OF INJURIES TO THE ANTERIOR PART OF THE NECK Soft-tissue injuries (cont’d)  Impaled objects can present life-threatening problems. Do not remove impaled objects unless they interfere with the airway.

PATHOPHYSIOLOGY OF INJURIES TO THE ANTERIOR PART OF THE NECK Injuries to larynx, trachea, and esophagus  Significant 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:  Bruising  Redness to the overlying skin  Palpable 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 ligaments  Provide cervical spine stabilization. Strain: stretching or tearing of muscle or tendon  Cervical 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, elevation  Soft 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.