Chapter 28: Face and Neck Injuries

Introduction

• Face and neck are vulnerable to injury.

  • Relatively unprotected positions on body

  • — — injuries and —- are common and vary in severity.

• Some injuries are life-threatening.

  • Penetrating trauma to the neck may cause severe ——.

  • Open injury may result in an — —.

soft tissue, fractures, bleeding, air embolism 

The Head 

• Cranium

  • Contains the —

  • Most posterior portion is called the —.

  • Lateral portions on each side are called temples or — regions.

  • Forehead is called the — region.

  • Anterior to the ear, in the temporal region, you can feel the pulse of the superficial — artery.

brain, occiput, temporal, frontal, temporal 

The Face

• Six major bones include:

  • — bone

  • Two —

  • Two —

  • —

• The — of the eye is composed of:

  • Lower edge of the frontal bone of the skull

  • Zygoma

  • Maxilla

  • Nasal bone

• — the eye from injury

• Only the proximal third of the nose is formed by —.

  • The remaining two thirds are composed of —.

• The exposed portion of the ear is composed entirely of — covered by skin.

  • Pinna

  • Tragus

  • Superficial temporal artery

• About 1 inch posterior to the external opening of the ear is the — —.

• The mandible forms the — and —.

nasal, zygomas, maxillae, mandible

orbit

protects

bone, cartilage

cartilage

mastoid process, jaw chin

The Neck

• Contains many important structures

• Supported by the — —

• The upper part of the esophagus and the trachea lie in the — of the neck.

• The — arteries are found on either side of the —.

• The larynx

  • Adam’s apple is located in the center of the neck.

  • Other portion of the larynx is the — cartilage.

  • The — membrane lies between the thyroid cartilag and the cricoid cartilage

• The trachea

  • — the larynx 

  • Connects the oropharynx and larynx with the main passages of the —

• Sternocleidomastoid muscles

  • Originate from the — —

  • Allow movement of the —

cervical spine, midline

carotid, trachea, cricoid

cricothyroid

below, lungs

mastoid process, head

The Eye

• Globe-shaped, approximately 1 inch in diameter

• Located within a bony socket in the skull called the —-

  • Composed of adjacent bones of the face and skull

  • Protects over 80% of the eyeball

• Clear, jellylike fluid near the — of the eye is called — —.

• In — of the lens is a fluid called the — —, which can leak out in penetrating injuries.

• The —- is the membrane that covers the eye.

• The — glands produce fluid to keep the eye moist.

• The — is the white, fibrous tissue that helps maintain the globular shape.

orbit

back, vitreous humor

front, aqueous humor

conjunctiva

lacrimal

sclera

The Eye

• On the front of the eye, the sclera is replaced by a clear, transparent membrane called the —.

  • Allows — to enter the eye

  • The — is a circular muscle behind the cornea.

• The — is the opening in the center of the iris.

  • Allows light to move to the — of the eye

  • Anisocoria is a condition in which a person is born with —- — pupils.

• The — lies behind the iris.

  • Focuses images on the — at the back of the globe

• The retina contains — —.

  • Respond to light by transmitting nerve impulses through the — nerve to the brain

  • The retina is nourished by a layer of blood vessels called the —.

  • Retinal detachment causes —-.

cornea, ligh, iris, pupil, back

different sized

lens, retina

nerve endings

optic

choroid

blindness

Injuries of the Face and Neck

• Can often lead to partial or complete obstruction of the — —

• Several factors may contribute.

  • Blood — from heavy facial bleeding

  • — injuries to the nose and mouth, larynx, and trachea

  • Dislodgment of — or — into the throat

  • — that accompanies direct and indirect injury

  • Airway may be affected when the patient’s head is turned to the —

  • Possible injuries to the — and/or — —

• Significant blunt force trauma to the trachea can blow both — —

upper airway 

clots, direct 

teeth dentures

swelling 

side 

brain cervical spine carotid arteries 

Soft-Tissue Injuries

• Face and neck are extremely —.

  • — may be more severe.

  • Skin and tissues in these areas have a rich — —.

  • A blunt injury can cause a —.

vascular

swelling

blood supply

hematoma

Dental Injuries

• Mandible fractures are common.

  • Most injuries are the result of vehicle collisions and assaults.

  • Signs of mandible fractures include:

    • Misalignment of the —

    • Numbness of the —

    • An inability to open the —-

• Maxillary fractures are usually found after blunt-force, high-energy impacts.

  • Signs of maxillary fractures include:

    • Massive facial —

    • Instability of the — —

    • Misalignment of —

    • Extreme pain

• — and —ok teeth are common following facial trauma.

teeth, chin, mouth

swelling, facial bones, teeth 

fractured avulsed 

Scene Size-up

• Scene safety

  • Observe for hazards and threats.

  • Assess for potential violence and environmental hazards.

  • Eye protection and face mask are standard.

  • Determine the number of patients.

• Mechanism of injury/nature of illness

  • Assess the scene.

  • Common MOI for face and neck injuries:

    • Motor vehicle collisions

    • Sports

    • Falls

    • Penetrating trauma

    • Blunt trauma

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Primary Assessment

• Focuses on identifying and managing life-threatening concerns

• Threats to XABCs must be treated immediately. 

  • When there is life-threatening external hemorrhage, it should be addressed before airway and breathing. 

• Form a general impression.

  • Look for important indicators about the seriousness of the patient’s condition.

  • Injuries may be very obvious or hidden.

  • Control blood loss with direct pressure.

  • Consider the need for manual spinal stabilization.

  • Check for responsiveness using the AVPU scale.

• Airway and breathing

  • Ensure a clear and patent airway.

  • If the patient is unresponsive or has significantly altered LOC, consider a properly sized oropharyngeal airway.

  • Quickly assess for adequacy of breathing. 

  • Palpate the chest wall for DCAP-BTLS.

  • Splinting or otherwise restricting chest wall motion is contraindicated. 

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Primary Assessment

• Circulation

  • Quickly assess pulse rate and quality.

  • Determine skin condition, color, and temperature.

  • Check capillary refill time.

  • Significant bleeding is an immediate life threat.

• Transport decision

  • Consider quickly transporting patients with airway or breathing problems or with significant bleeding.

  • Consider ALS backup.

  • A patient with internal bleeding must be transported quickly for treatment by a physician.

  • Signs of hypoperfusion imply the need for rapid transport.

  • The patient who has a significant MOI but whose condition appears stable should be transported promptly.

  • Any significant blow to the face or throat should increase your suspicion of —- or — injury.

spine, brain

Secondary Assessment

• Physical examinations

  • If multiple systems have been affected, start with an assessment of the entire body, looking for DCAP-BTLS.

  • Do not delay transport to complete a thorough physical examination.

  • In a responsive patient with an isolated injury with limited MOI, consider focusing on the isolated injury, the patient’s chief complaint, and the body region affected.

  • Ensure that control of bleeding is maintained and note injury location.

  • Inspect the open wound for any foreign matter and stabilize impaled objects.

  • Use both your eyes and your hands.

  • Assess all underlying systems.

  • When evaluating the eyes, start with the outer aspect and work toward the pupils.

  • Examine the eye for any obvious foreign matter. 

  • Visual acuity is a vital sign of the eye. 

  • Look for discoloration, bleeding, redness, eye symmetry, and pupil size and reaction to light.

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Secondary Assessment

• Vital signs

  • Assess vital signs to obtain a baseline.

  • You must be concerned with visible bleeding and unseen bleeding inside a body cavity.

  • With facial and throat injuries, baseline information is very important.

  • Use appropriate monitoring devices

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Reassessment

• Repeat the primary assessment.

• Reassess vital signs and the chief complaint.

  • Reassess the patient’s condition at least every 5 minutes.

• Interventions

  • Provide complete spinal immobilization if necessary.

  • Maintain an open airway, be prepared to suction, and consider an oropharyngeal airway.

  • Whenever you suspect significant bleeding, provide high-flow oxygen.

  • Control significant visible bleeding.

  • If the patient has signs of hypoperfusion, treat aggressively for shock and provide rapid transport.

• Communication and documentation

  • Include a description of the MOI and the position in which you found the patient.

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Emergency Medical Care

• Treat soft-tissue injuries to the face and neck the same as soft-tissue injuries elsewhere on the body.

  • Assess XABCs and life threats first.

  • Follow standard precautions. 

  • In the absence of life-threatening bleeding, first — and — the airway.

  • Avoid moving the — in patients with suspected cervical spine injuries.

• Control bleeding by applying — — — with a dry, sterile dressing (or hemostatic dressing)

  • Use — gauze, wrapped around the head, to hold a —- dressing in place.

  • Do not apply excessive pressure if an underlying — — is suspected (broken fragments can push into brain)

open clear, neck, direct manual pressure

roller, pressure

skull fracture

Emergency Medical Care

• Cover exposed brain, eye, or other structures with a —, — dressing.

• Apply — locally to injuries that do not break the skin.

• For soft-tissue injuries around the mouth, check for — inside the mouth.

• Physicians can sometimes graft a piece of avulsed skin back into position.

  • If you find portions of avulsed skin:

    • Wrap in a — dressing.

    • Place in a plastic bag.

    • Keep —, but do NOT place — on ice

    • Label and deliver to the emergency department.

• If the avulsed skin is still attached in a loose flap:

  • Place the flap in position as close to — as possible.

  • Hold in place with a —, — dressing.

moist sterile

ice

bleeding

sterile, cool, directly

normal, dry sterile

Injuries of the Eyes

• Eye injuries are common, particularly in sports.

  • Can produce lifelong complications, including blindness

• After an injury, pupil — or —, and eye — are disturbed.

• Any loss of vitreous humor (leaking out) will almost always lead to —-

• Treatment starts with a thorough examination.

  • Always use standard precautions.

  • Take care not to aggravate any problems.

  • Look for abnormalities or conditions that may suggest the nature of the injury.

reaction shape, movement blindness 

Injuries of the Eyes

Foreign objects

• The — protects the eye from the penetration of large objects.

• Even a small object may produce severe —.

• Irrigation with a sterile —- solution will frequently flush away loose particles.

• Always flush from the — side of the eye toward the —- to avoid flushing material into the other eye.

• A foreign body will leave a small abrasion on the —-.

• Gentle irrigation may not wash out foreign bodies stuck to the cornea or lying under the upper eyelid.

• Foreign bodies may be impaled in the eye - DO NOT —

  • May compromise the — —

• Bandage the object in — to support it.

• Cover the eye with a —, — dressing.

• Surround the object with a doughnut-shaped collar.

• When you see or suspect an impaled object(s) in the eye, bandage —- eyes with soft, bulky dressings to prevent further injury. 

orbit, irritation, saline 

nose, outside

conjunctiva 

remove, vitreous humor

place, moist sterile 

both 

Injuries of the Eyes

• Burns of the eye

  • — the burn and — further damage.

• Chemical burns

  • Usually caused by acid or alkaline solutions

  • Flush the eye with water or saline.

  • Direct the — amount of irrigating solution or water into the eye as — as possible.

  • You may have to force the lids open.

  • Flush from the — to — corner. 

  • If the burn was caused by an alkali or a strong acid, irrigate continuously for at least —- —-.

  • After irrigation, apply a clean, dry dressing to cover the eye and transport.

• Thermal burns

  • During a fire, the eyes will close to protect from heat, and the —- will burn.

  • Transport promptly without further examination.

  • Cover both eyes with a sterile dressing —- with sterile saline.

  • Apply eye —- over the dressing.

stop, prevent

flush, greatest, gently, inner outside, 20 minutes 

eyelids, moistened, shields 

Injuries of the Eyes

• Light burns

  • Infrared rays, eclipse light, and laser beams all can cause significant damage.

  • Retinal injuries caused by exposure to light are generally —- painful but may result in — damage.

  • Severe conjunctivitis usually develops with redness, swelling, and excessive tears.

• Lacerations

  • Require very careful repair to restore appearance and function

  • We —- put direct pressure on the eyes

  • Bleeding may be heavy, but it usually can be controlled with —-, manual pressure.

  • If there is a laceration of the globe itself, apply —- pressure to the eye.

  • On rare occasions, the eyeball may be displaced from its socket.

    • Do not attempt to reposition it.

    • Cover the eye and stabilize it with a — — dressing

    • Cover —- eyes to prevent further injury.

    • Have the patient lie —-.

not, permanent, conjunctivitis

never, gentle, no

moist sterile, both, supine

Injuries of the Eyes

• Blunt trauma

  • Hyphema obscures all or part of the iris

    • Collection of —- between the —- and —-

  • An orbit fracture is a fracture of the bones that form the eye —- and support the —-.

  • — detachment is often seen in sports.

• Eye injuries following head injury

  • Signs and symptoms of a possible head injury:

    • One pupil —- than the other

    • Eyes not moving —

    • Failure of the eyes to — your finger

    • Bleeding under the —

    • Protrusion or bulging of one eye

blood, cornea, iris, floor, globe 

retinal 

larger, together, follow, conjunctiva

Injuries of the Eyes

• Blast injuries

  • Signs and symptoms range from severe pain and loss of vision to foreign bodies within the globe.

  • If there is a foreign body within the globe, do — remove it.

  • If only one eye is injured, follow local protocol.

  • If the patient has severe swelling, do not force the eyelid open to examine it.

• Contact lenses and artificial eyes

  • Do not attempt to remove contact lenses unless there is a —- burn.

  • To remove a hard contact lens, use a small — —.

  • To remove soft contact lenses, place one or two drops of —- in the eye, — the lens between your thumb and index finger, and lift.

not

chemical, suction cup, saline, pinch

Injuries of the Nose

• Nosebleeds (—-) are a common problem.

  • One of the most common causes is digital trauma.

  • Anterior nosebleeds usually originate from the area of the —- and bleed —.

  • Posterior nosebleeds are usually more —- and often cause blood to drain into the —-.

• Blunt injuries to the nose may be associated with fractures and soft-tissue injuries of the face, head injuries, and/or injuries to the cervical spine.

• Assess the nose —- for injury.

• Patients with severe nasal injury may also have — — injury.

• — may escape down through the nose following a fracture at the — of the skull.

  • Will see on gauze as a — circle … if bleeding as well will see the — —

• Control bleeding by applying a sterile dressing, no pressure!

epistaxis, septum, slowly, severe, throat

structures, cervical spine

CSF, base , yellow, halo sign

Injuries of the Ear

• Divided into three parts:

  • External ear

  • Middle ear

  • Inner ear

• Ears are often injured, but they do not usually bleed very much.

  • In case of an ear avulsion, wrap the avulsed part in a moist, sterile dressing and put it in a plastic bag.

• Tympanic membrane rupture

  • Patients will report severe ear pain, difficulty —, or — in the affected ear.

  • May be caused by — of objects too far into the ear

  • Will have altered — (issues with vestibular system on that side)

• Children place foreign bodies in the external auditory canal.

• Clear fluid coming from the ear may indicate a — —- (—-)

  • Look for halo sign

hearing, ringing, insertion, balance

skull fracture, CSF

Facial Fractures

• Typically result from blunt impact

• Assume a direct blow to the —- or —- has caused a facial fracture.

• Other clues include:

  • — in the mouth

  • Inability to — or —

  • Absent or loose —

  • Loose or movable bone fragments

• Facial fractures alone are not acute emergencies unless there is serious —-.

• Plastic surgeons can repair the damage to the face and mouth if the injuries are treated within 7 to 10 days.

• Swelling can be —- within the first 24 hours after injury.

mouth nose 

bleeding swallow talk teeth 

bleeding, severe 

Dental Injuries

• Can be traumatic to the patient

• — will occur whenever a tooth is violently displaced from its socket.

  • Apply — — to stop the bleeding.

  • Perform — if needed.

  • Cracked or loose teeth are possible — —.

• Save and transport an avulsed tooth.

  • Handle it by the — rather than the —.

  • Place the tooth in tooth storage solution, cold —, or sterile —.

  • Notify the hospital.

  • Re-implantation is recommended within — —- to — — after the trauma.

bleeding, direct pressure, suction, airways obstructions

crown, root, milk, saline, 20 minutes 1 hour

Injuries of the Cheek

• You may encounter an object impaled in the patient’s cheek.

  • If you are unable to control the bleeding, consider —- the object.

  • Provide direct pressure on the — and — of the cheek.

  • The amount of bandaging should not occlude the —.

removing, inside outside, mouth

Injuries of the Neck

• The neck contains many structures vulnerable to injury by blunt trauma.

  • Upper airway        

  • Esophagus

  • Carotid arteries and jugular veins

  • Thyroid cartilage (Adam’s apple)

  • Cricoid cartilage

  • Upper part of the trachea

• Blunt injuries

  • Any crushing injury of the upper part of the neck is likely to involve the — or —.

  • Can lead to loss of voice, difficulty swallowing, severe and sometimes fatal airway —, and leakage of — into soft tissues of the neck

  • — — is a characteristic crackling sensation produced by the presence of air.

  • Complete airway —- can develop rapidly.

  • Consider ALS support early. 

  • Consider spinal motion restriction.

larynx trachea

obstruction, air

subcutaneous emphysema

obstruction

Injuries of the Neck

• Penetrating injuries

  • Can cause profuse — from laceration of the great vessels in the neck

  • Injuries to the — and — veins can cause the body to bleed out (exsanguination).

  • Injuries to these large vessels may also allow —- to enter the circulatory system, which can lead to — — and — —.

  • — — will control most bleeding. 

  • Use — — to prevent air and liquids from and entering and exiting

bleeding, carotid jugular, air, air embolism cardiac arrest 

direct pressure, occulsive dressing 

Laryngeal Injuries

• Blunt force trauma to the larynx can occur when:

  • Unrestrained driver strikes steering wheel (less likely due to airbags)

  • Snowmobile rider strikes a clothesline.

• The larynx becomes crushed against the —- —-, resulting in soft-tissue injury, fractures, and/or separation of the fascia.

• Penetrating or impaled objects in the larynx should not be removed unless they interfere with —-.

  • — all impaled objects as long as they are not obstructing the airway.

cervical spine, CPR, stabilize

Laryngeal Injuries

• Signs and symptoms of larynx injuries:

  • Respiratory —-

  • Hoarseness

  • Pain

  • Difficulty — (—)

  • Cyanosis

  • Pale skin

  • — in the wound or bubbling from the wound

  • — —

  • Bruising on the neck

  • Hematoma

  • Bleeding

• To manage a laryngeal injury: 

  • Provide oxygen and ventilation. 

  • Apply cervical immobilization but avoid rigid collars.

distress swallowing, dysphagia, sputum, subcutaneous emphysema

Which of the following statements regarding the “Adam’s apple” is FALSE?

It is inferior to the cricoid cartilage.

It is formed by the thyroid cartilage.

It is the uppermost part of the larynx.

It is more prominent in men than in women.

It is inferior to the cricoid cartilage.

The globe of the eye is also called the:

lens.

orbit.

retina.

eyeball.

eyeball.

When a person is looking at an object up close, the pupils should:

dilate.

constrict.

remain the same size.

dilate, and then constrict.

constrict

When caring for a chemical burn to the eye, the EMT should:

prevent contamination of the opposite eye.

immediately cover the injured eye with a sterile dressing. 

avoid irrigating the eye, as this may cause further injury.

irrigate both eyes simultaneously, even if only one eye is injured. 

prevent contamination of the opposite eye.

Which of the following signs is LEAST indicative of a head injury? 

Asymmetric pupils

Pupillary constriction to bright light

Both eyes moving in opposite directions

Inability to look upward when instructed to

Pupillary constriction to bright light

The purpose of the eustachian tube is to:

move in response to sound waves.

transmit impulses from the brain to the ear.

equalize pressure in the middle ear when external pressure changes.

house fluid within the inner chamber of the ear and support balance.

equalize pressure in the middle ear when external pressure changes.

When caring for a patient with facial trauma, the EMT should be MOST concerned with:

spinal trauma.

airway compromise.

associated eye injuries.

severe external bleeding. 

airway compromise.

The presence of subcutaneous emphysema following trauma to the face and throat is MOST suggestive of:

esophageal injury.

cervical spine fracture.

crushing tracheal injury.

carotid artery laceration.

crushing tracheal injury.

A 21-year-old male has a large laceration to his neck. When you assess him, you note that bright red blood is spurting from the left side of his neck. You should immediately:

apply a pressure dressing to his neck.

sit the patient up to slow the bleeding.

place your gloved hand over the wound.

apply 100% oxygen via nonrebreathing mask.

place your gloved hand over the wound.

Which of the following mechanisms of injury would MOST likely cause a crushing injury of the larynx and/or trachea?

Attempted suicide by hanging

Gunshot wound to the lateral neck

Car crash involving lateral impact

Patient whose head hits the windshield

Attempted suicide by hanging