1. Eye, Face, and Neck Trauma
Chapter 33

2. Objectives Review the Anatomy of the Eye, Face, and Neck
Assessment-based Approach: Eye, Face and Neck
Discuss Specific Injuries Involving the Eye, Face and Neck

3. The Eye Globe (eyeball) Sclera Cornea Pupil Iris Lens Retina
Conjunctiva
Anterior Chamber
Aqueous humor
Vitreous body
Vitreous humor
Orbits (eye sockets)

4. The Face
Comprised of 14 skull bones – 13 of the facial bones are immovable
Extremely vascular
Provide minimum protection for airway
Allow points of attachment for muscles that control facial expression and manipulation of food
Compromise of facial structure can also cause closed or open brain injury
Mechanism that causes injury to the face is likely to have injured the spine as well

5. The Neck Body systems within the neck
Cardiovascular – Carotid arteries and jugular veins
Musculoskeletal
Central nervous
Respiratory
Digestive
Endocrine
Major structures
Trachea and larynx
Major concerns
Damages to structure of airway are serious life threats
Any neck injury should be automatically assumed to have caused spinal injury

6. Assessment-based Approach
Scene Size-up
Think of forces behind injury after dispatch
Motor Vehicle crashes – over 50% of all facial trauma
Assault
Sports related injuries
Gather information from bystanders
Protect your own safety

7. Primary Assessment Manual in-line stabilization Control major bleeding
Open airway with jaw-thrust and suction vomit
Consider ALS
Oxygen via 15 lpm
Recognize high priority injuries;
Eye: Chemical burns, Impaled objects
Respiratory distress
Severe injuries to face or neck
Major bleeding
Airway compromise

8. Secondary Assessment
Inspect and palpate for injury to eye sockets, cheekbones, nose and jaw
Use penlight to examine eyes
Record vital signs
If severely bleeding, prepare to treat for shock
Obtain a history
Ask questions about the events leading up to the injury

9. Reassessment Reassess and check interventions
Unstable: every 5 minutes
Stable: every 15 minutes
Monitor for deterioration

10. Injuries to the Eye Assessment and Care Guidelines
Use a penlight to evaluate;
Orbits: bruising, swelling, lacerations, tenderness
Lids: bruising, swelling, laceration
Conjunctivae: redness, pulsing, foreign bodies
Globes: redness, abnormal color, laceration
Pupils: Size, shape, equality, reactivity (PEERLS)

11. Assessment and Care Guidelines
Test whether the eyes can follow your finger normally as you move it up, down, left, right
Basic rules;
Avoid unnecessary manipulation when swollen shut
Don’t try to force the eyelid open, unless to wash it out
No salve or medication in injured eye
Don’t remove blood/blood clots
Have patient lie down & be quiet
Give nothing by mouth
Transport all eye injury patients
Never apply direct pressure to an injured eye

12. Foreign Object in the Eye
Determine if anyone has attempted to remove the object
Attempt to remove only if in conjunctiva

13. Removing the object - Flushing
Flush with clean water

14. Removing the object
Pull down lid while patient looks up, or pull up on lid as patient looks down; remove with sterile gauze or swab
Draw upper lid over lower lid, then back, allowing lower lashes to dislodge object
Grasp upper lashes to turn lid upward; remove object
Pull lower lid down and remove object
Do not remove object lodged in globe; bandage both eyes and transport ASAP

15. Injury to the Orbits Establish/maintain spine stabilization
Look for signs/symptoms or orbital fracture;
Diplopia – double vision
Marked decrease in vision
Loss of sensation above eyebrow, over the cheek, or in upper lip
Nasal discharge
Tenderness to palpation
Bony “step off” – detect in smooth contour of bone
Paralysis of upward gaze
Eyeball uninjured – place cold packs over injured eye, transport in sitting position.
Eyeball injured – Don’t use cold packs, transport in supine position

16. Lid Injury Inspect for evidence of injury
Control bleeding with light pressure
Use no pressure if eyeball injured
Cover lid with sterile gauze soaked in saline to keep from drying
Preserve avulsed skin and transport
Eyeball uninjured: cover with cold compress
Cover uninjured eye with a bandage to decrease movement
Transport

17. Injury to the globe Use caution; are best treat at the hospital
Apply patches lightly to both eyes
Don’t apply patch if you suspect ruptured eyeball
Avoid cold packs
If you use an eye shield, be sure it puts no pressure on injury
Keep patient supine

18. Chemical Burn to the Eye
Begin treatment immediately!
Never irrigate with any chemical antidote (alcohol/sodium bicarbonate)
Remove or flush out contact lenses
Place patient on their side on stretcher, with basin/towel under the head, continue to irrigate during transport
Following irrigation, wash hands thoroughly and clean under your nails with a nail brush.

19. Irrigation Irrigate with clean water or sterile saline
Hold the eyelids open so all chemicals can be washed out.
Continue to irrigate for at least 20 minutes – if alkali is involved, at least an hour – until arrival at hospital
Use running or continually pour from the inside corner
May have to force lids open
Take care not to contaminate uninvolved eye

20. Removal of Foreign Object EMT Skill 33-1

21. Impaled Object/Extruded eyeball
Place in supine position, immobilize head and spine
Encircle eye and impaled object or extruded eyeball with a gauze dressing.
Do not apply pressure; cut a hole in the dressing to accommodate impaled object
Place a metal shield, crushed paper cup, or cone over the impaled object
Hold cup and dressing in place with a bandage that covers both eyes; close the uninjured eye before bandaging
Give patient nothing by mouth, never leave patient alone, and constantly provide assurance
Transport immediately

22. Impaled Object in the Eye EMT Skill 33-2

23. Removing Contact Lenses
When to remove;
If there has been a chemical burn to the eye
If patient is unresponsive and wearing hard lenses
If transport time is lengthy or delayed
When not to remove;
If eyeball is injured (excluding chemical burns)
Short transport time

24. Removing Soft Contact Lenses
Place several drops of saline on lens, lift off eye by pinching lens between thumb and forefinger
Steps;
Pull down lid
Place index finger on lower edge of lens, slide lens down to white of eye
Compress lens between thumb and forefinger
If dehydrated, run sterile saline across it, then slide off cornea, and pinch
Store in water or saline solution

25. Removing Hard Contact Lenses
Separate eyelids
Position lens over cornea
Place thumbs gently on top and bottom of eyelids, open wide
Press eyelids down and forward to edge of lens
Press lower eyelid slightly harder and move under the bottom edge of lens
Moving eyelids toward each other, slide lens out between them
Or, use a contact lens removal kit

26. Injuries to the Face Assessment and Care Guidelines
Establish/maintain in-line stabilization
Establish/maintain airway
Inspect mouth for small fragments of teeth, bits of bone, pieces of flesh or foreign objects, remove as thoroughly as possible
If dentures whole, leave in place; broken of loose, remove them, transport with patient
Open airway with jaw-thrust
Suction blood, vomit, secretions or small debris
Request ALS to provide advanced airway management

27. Assessment and Care Guidelines
Oxygen via 15 lpm; if breathing inadequate, PPV with supplemental oxygen
Control severe bleeding
Cover any exposed nerves, tendons, or blood vessels with moist sterile dressing
Treat for shock and transport

28. Avulsed Tooth If tooth is lost, try to find it; may be reimplanted
Rinse tooth with saline and transport in a cup of saline or wrapped in gauze that has been soaked in saline
Never handle by the root
If you can’t find lost teeth, assume the patient has swallowed or aspirated them
Control bleeding from tooth socket with a gauze pad

29. Injuries to Midface, Upper Jaw/Lower Jaw
Signs/Symptoms of fracture or other severe trauma
Numbness/pain
Distortion of facial features
Crepitation
Irregularities in facial bones
Severe bruising/swelling; black eyes
Distance between eyes too wide; not level
Bleeding from nose/mouth
Diplopia
Limited jaw motion
Palpable movement to maxilla
Teeth not meeting normally
Hematoma under the tongue
Mouth open or patient unable to open mouth
Saliva/blood flowing from mouth, or drooling
Painful/difficult speech
Missing, loose, or uneven teeth
Pain around ears

30. Object Impaled in Cheek
Stabilize with bulky dressing
Remove if it has pierced through cheek into mouth or is loose and may fall into mouth;
Pull or push out of cheek in opposite direction to which it entered
Pack dressing material between patient’s teeth and wound; tape dressing to outside of mouth prevent swallowing
Dress and bandage outside of wound
Consider ALS
Suction mouth and throat frequently throughout transport

31. Injury to the Nose Take care to maintain open airway
Position patient so blood does not drain into the oropharynx or pharynx
Never pack injured nose; packing can create dangerous pressure if skull fractured
Apply cold compress to reduce swelling, and transport
Do not try to remove a foreign object from the nose; reassure and calm the patient and transport

32. Injury to the Ear
Save avulsed ear parts, wrap in saline-soaked gauze and transport with patient
When dressing an injured ear, place dressing between ear and head
Do not probe into the ear
Never pack the ear to stop blood flow from ear canal; place a loose, clean dressing across ear opening to absorb blood and fluids
Do not attempt to remove a foreign object from the ear; reassure the patient and transport

33. Injuries to the Neck Common causes of neck injuries
Hanging (accidental or intentional)
Impact with a steering wheel
Knife wound
Gunshot wound
Running or riding into stretched wire or clothesline
Fractured larynx
Collapsed trachea
Cervical spine injury

34. Signs/Symptoms Obvious swelling, bruising, or hematoma
Difficulty speaking
Change in or loss of voice
Subcutaneous emphysema in neck
Airway obstruction that is not obviously due to other sources
Crepitation heard during speaking or breathing
Displacement of trachea to one side (also a sign of chest injury)

35. Treatment Use BSI Maintain in-line stabilization
Establish patent airway
Provide high-flow, high-concentration oxygen or PPV
Control severe bleeding
Treat for shock
Transport

36. Special consideration for treatment
If jugular vein is lacerated, immediately apply occlusive dressing
If a major blood vessel of the neck is severed, follow the guidelines for soft-tissue injuries
Never probe open wounds
Never use circumferential bandages

37. Emergency Care – Severed Blood Vessel in the Neck EMT Skills 33-8

38. Questions ????