Face and Neck Injuries

The Head:

  • Cranium contains brain, most posterior portion is the occiput, lateral portions on each side are temporal regions, forehead is frontal, anterior to the ear in the temporal region you can feel a pulse of the superficial temporal artery.

Face:

  • 6 major bones include: Nasal bone, two zygomas, two maxillae, mandible

  • The orbit of eye is composed of: lower edge of the frontal bone of the skull, zygoma, maxilla, nasal bone.

  • Only proximal third of nose is formed by bone

  • Exposed portion of the ear is composed entirely of cartilage covered by skin

The Neck:

  • The larynx is where Adam’s apple is located, other portion of the larynx is the cricoid cartilage.

  • The cricothyroid membrane lies between the thyroid, cartilage and the cricoid cartilage.

  • The trachea is below the larynx, connects oropharynx and larynx with main passages of the lungs.

  • Sternocleidomastoid muscles originate from mastoid process, and allow movement of the head.

The Eye:

  • About 1 inch in diameter.

  • Clear, jellylike fluid near the back of the eye is called vitreous humor.

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

  • The conjunctive is the membrane that covers the eye.

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

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

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

    • Allows light to enter eye, iris is a circular muscle behind the cornea

  • Pupil is the opening in the center of the iris.

    • Allows light to move to the back of the eye, anisocoria is a condition in which a person is born with different sized pupils.

  • Lens lies behind the iris, which focuses images on the retina at the back of the globe

  • Retina contains nerve endings, respond to light by transmitting nerve impulses through the optic nerve to the brain.

    • The retina is nourished by a layer of blood vessels called the choroid, and retinal detachment causes blindness.

Injuries to Face and Neck:

  • Can often lead to partial or complete obstruction of the upper airway

Soft-Tissue Injuries:

  • Face and neck are extremely vascular

  • Swelling may be more severe, skin and tissues in these areas have a rich blood supply

  • A blunt injury can cause a hematoma

Dental Injuries:

  • Signs of mandible fractures:

    • Misalignment of teeth

    • Numbness of chin

    • An inability to open the mouth

Emergency Medical Care:

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

  • Cover exposed brain, eye, or other structures with moist, sterile dressing.

  • Wrap portions of avulsed skin in sterile dressing, place in plastic bag, keep cool but not directly on ice, label and deliver to the ED.

    • If flap is attached, place it in as close to normal position as possible, hold in place with dry, sterile dressing

Injuries of the Eyes:

  • Irrigation with sterile saline solution will frequently flush away loose particles.

    • Always flush away from the nose side of the eye toward the outside to avoid flushing material into other eye

  • If foreign body is impaled in the eye, bandage the object to support it. Cover eye in moist, sterile dressing and surround the object with a doughnut-shaped collar. When you see or suspect an impaled object(s) in the eye, bandage both eyes with soft, bulky dressings to prevent further injury

  • Stop burns in eye and prevent further damage

  • Flush chemical burns with water or saline, direct the greatest amount of irrigating solution or water into the eye as gently as possible

    • If burn was caused by an alkali or strong acid, irrigate continuously for at least 20 minutes. Afterwards, apply clean, dry dressing to cover the eye for transport

  • Thermal burns: Transport promptly without further examination. Cover both eyes with sterile dressing moistened with sterile saline. Apply eye shields over dressing

  • Light Burns: Retinal injuries caused by exposure to light are generally not painful but may result in permanent damage. Severe conjunctivitis usually develops with redness, swelling, and excessive tears.

  • Lacerations: Require very careful repair to restore appearance and function. Bleeding may be heavy but gentle manual pressure can control it. If there is laceration to the globe itself, apply no pressure to eye. Do NOT attempt to reposition eye if displaced, cover eye and stabilize it with moist sterile dressing, and cover both eyes to prevent further injury while having them lie supine.

  • Blunt trauma: Hyphema obscures all or part of the iris, with retinal detachment often seen in sports.

    • S/S: One pupil bigger than other, eyes not moving together, failure of eyes to follow finger, bleeding under conjunctiva, protrusion or bulging of one eye.

  • Blast Injuries: S/S range from severe pain and loss of vision to foreign bodies within the globe. If there is foreign body within the globe, do not remove it. If one eye is injured, do not remove it. If only one eye is injured, follow local protocol. Do not force swollen eyelid open to examine it.

  • Contact lenses and artificial eyes: Don’t attempt to remove contact lenses unless there’s chemical burn.

    • Use small suction cup to remove hard contact lenses. To remove soft contacts, place one or two drops of saline in the eye, pinch the lends between thumb and index finger, and lift.

Injuries to the Nose:

  • Nosebleeds (epistaxis) are a common problem.

    • One of most common causes is digital trauma.

    • Anterior nosebleeds usually originate from the area of the septum and bleed slowly.

    • Posterior nosebleeds are usually more severe and often cause blood to drain into the throat.

  • Check for CSF escaping from nose following facial trauma. Control bleeding via sterile dressing.

Injuries of the Ear:

  • Divided into 3 parts: External ear, middle ear, inner ear.

  • In case of 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 hearing, or ringing in the affected ear.

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

  • Don’t remove impaled objects.

Facial Fractures:

  • Not acute emergencies unless there is serious bleeding

Dental:

  • Save and transport avulsed tooth. Handle it by crown rather than root, store in cold milk, sterile saline, or storage solution.

  • Reimplantation recommended within 20 minutes to 1 hour after trauma.

Injuries of the Cheek:

  • If unable to control the bleeding, consider removing the object.

  • Provide direct pressure on the inside and outside of cheek.

  • Bandaging should not occlude the mouth.

Injuries of the Neck:

  • Blunt injuries

    • Any crushing injury of the upper part of neck is likely to involve larynx or trachea. Can lead to loss of voice, difficulty swallowing, severe and sometimes fatal airway obstruction, and leakage of air into soft tissues of the neck.

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

    • Consider ALS support early and spinal stabilization

  • Penetrating Injuries:

    • Injuries to these large vessels may also allow air to enter the circulatory system, which can lead to air embolism and cardiac arrest. Direct pressure will control most bleeding.

Laryngeal Injuries:

  • Larynx becomes crushed against the cervical spine, 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 CPR, stabilize all impaled objects if they’re not obstructing the airway.

  • S/S: Subcutaneous emphysema, bruising on the neck, hematoma, bleeding.

  • Management: Provide oxygen and ventilation, apply cervical immobilization but avoid rigid collars.