Face and Neck Injuries

Cranium and Skull

• The cranium is the largest part of the head, also known as the skull.
• It houses and protects the brain.
• The posterior part of the cranium is the occiput.
• Vision is occipital, and the occiput is the bone covering that area.
• The lateral portions are the temples or temporal regions.
• The forehead is the frontal region.
• Anterior to the ear (in front of the tragus) is the superficial temporal artery, where a pulse can be palpated.

Facial Bones

• The face is composed of six major bones:
  • Nasal bone (back of the nose).
  • Two zygomas (cheekbones).
  • Two maxillae (top jaws).
  • Mandible (main movable part of the jaw).
• The orbit (eye socket) is formed by the frontal bone, nasal bone, zygomas, and maxilla.
• The external ear is called the pinna.
• The tragus is the small, rounded fleshy part anterior to the ear canal.
• The superficial temporal artery can be palpated in front of the tragus, but it may be difficult to feel.

Neck Anatomy

• The neck protects vital structures and is supported by the cervical spine (seven vertebrae).
• The spinal cord exits through the foramen magnum (large hole) at the base of the skull.
• The atlas and axis are the first two cervical bones outside the foramen magnum.
• Internal decapitation refers to the dislocation of the atlas from the foramen magnum.
• The neck also contains the airways (esophagus and trachea), carotid arteries, and cricoid thyroid.
• The Adam's apple, or laryngeal prominence, is located in the anterior center of the neck.
• It is more prominent in males and is a firm cartilaginous ridge.
• The trachea's rigid rings are essential for maintaining airway patency.
• The cricothyroid membrane lies between the cricoid cartilage and thyroid cartilage.
• This is the location for surgical cricothyrotomies.
• The trachea is below the larynx and connects to the oral pharynx, larynx, and lungs.

Eye Anatomy

• The eye (globe) is about one inch in diameter and sits within the bony orbital socket.
• The orbit protects approximately 80% of the eyeball.
• The vitreous humor, a jelly-like fluid, maintains the eye's shape.
• The aqueous humor is a more liquid substance located in front of the lens.
• The conjunctiva is the membrane covering the eye.
• Lacrimal glands produce tears to keep the eye moistened.
• Tears drain into lacrimal ducts, which drain into the nasal cavity.
• The sclera is the white part of the eye and maintains shape with the vitreous humor.
• The cornea is a transparent membrane on the front of the eye that allows light to enter.
• The pupil is the opening in the center of the iris through which light penetrates the eye.
• Anisocoria is a condition where a person is born with or develops different-sized pupils.
• The lens is located behind the iris and focuses images onto the retina.
• The retina contains nerve endings (rods and cones) that respond to light.
• The optic nerve connects the retina to the occipital lobe in the brain for processing visual information.
• Images are seen backwards and upside down, and the occipital lobe corrects the orientation.
• The retina has a thick layer of blood vessels.
• Retinal detachment occurs when the retina detaches from the nerve, leading to blindness.

Face and Neck Injuries: Airway Considerations

• Injuries to the face and neck can lead to airway obstruction due to:
  • Bleeding and clot formation.
  • Direct injuries occluding the airway.
  • Lacerations or penetration of the trachea.
  • Dislodgement of teeth or dentures.
  • Swelling.
  • Positioning affecting the airway.
  • Injuries to the brain and cervical spine affecting breathing.
• The face and neck are highly vascularized, leading to more swelling and bleeding.
• Blunt injuries can cause hematomas.

Common Injuries

• Mandible injuries are common.
• Nasal fractures are the most common facial trauma, often caused by vehicle crashes and assaults.
• Signs of mandible fractures include:
  • Misalignment of teeth.
  • Numbness of the chin.
  • Inability to move the jaw.
• Maxillary fractures result from high-energy impacts.
• Signs of maxillary fractures include:
  • Facial swelling.
  • Instability of facial bones.
  • Misalignment of upper teeth.
• Fractured or avulsed teeth are common after facial trauma.
• Fragments can obstruct the airway and cause lacerations.

Safety and Precautions

• Ensure personal safety, then partner safety, then patient safety.
• Use standard precautions, including gowns and face shields, to prevent contamination.
• Common mechanisms of injury (MOIs) for face and neck injuries include motor vehicle crashes (MVCs), sports-related injuries, falls, and blunt or penetrating traumas.

Eye Assessment

• Assess the eyes for:
  • Bloodshot appearance.
  • Foreign matter.
  • Vascular rupture within the sclera.
  • Discoloration.
  • Bleeding.
  • Redness.
  • Symmetry.
  • Pupil size and reaction to light.

Management of Eye Injuries

• Cover exposed brain tissue with a moist sterile dressing.
• Apply ice locally to closed injuries (RICE mnemonic).
• For soft tissue injuries around the mouth, check for teeth or other obstructions.
• For facial bleeding, a cravat cap can be used to apply pressure and absorb blood.
• Do not apply excessive pressure to the skull if a fracture is suspected.
• For avulsed skin segments, wrap in a sterile dressing. If detached, place in a plastic bag, keep dry and cool (do not place directly on ice).

Avulsions

• For avulsed segments:
  • Place the skin flap in its anatomically correct position using a dry sterile dressing to hold it in place.
  • Keep it dry and cool.

Eye Injuries

• Eye injuries are common, especially in sports, and can result in lifelong vision loss.
• Pupil reaction and eye shape are often disturbed after an eye injury.
• Abnormal pupil reactions can indicate brain injury.
• The orbit protects the eyes, exposing only 20-30% of the eye to potential injury.
• Foreign bodies can cause abrasions on the conjunctiva.
• To remove foreign bodies from the eye, gently flush with a nasal cannula and sterile solution.
• Stabilize impaled objects in the eye and cover both eyes to prevent movement.

Eye Burns

• Chemical burns to the eye should be irrigated with sterile saline or water from the inner to the outer corner using a nasal cannula.
• Eye irrigation stations or sterile water bottles can also be used.
• For thermal burns, cover both eyes and apply eye shields over the dressing.
• Light burns can be caused by infrared lights, eclipses, and laser beams.
• Superficial burns can result from UV rays, welding, or bright light reflected from snow, causing conjunctivitis (redness, swelling, and excessive tear production).

Lacerations and Dislocations

• Lacerations to the globe: Gently apply a moist sterile dressing, but do not apply pressure.
• For dislocated eyes, do not attempt to push them back in. Support with a donut-shaped dressing and cover with a moist sterile dressing. Keep the patient supine.

Hyphema and Orbital Fractures

• Hyphema is bleeding into the anterior chamber of the eye.
• Orbital fractures can entrap eye muscles, causing an inability to move the eyes.

Head Injuries and Anisocoria

• Anisocoria, or unequal pupil size, should be considered a sign of head injury until proven otherwise.
• Also check for fixated dilated or constricted pupils.

Blast Injuries

• Blast injuries can cause severe eye pain, loss of vision, and foreign bodies in the eye.
• Avoid forcing the eye open if there is severe swelling.

Contact Lenses

• If a patient has chemical burns, remove their lenses.
• Remove hard contacts with a suction cup and soft contacts by pinching with fingers.

Nosebleeds (Epistaxis)

• Epistaxis, or nosebleeds, are commonly caused by digital trauma (nose picking).
• Anterior epistaxis occurs at the septum.
• Posterior nosebleeds are more critical as blood flows down the throat.
• A deviated septum is when the nasal septum isn't in the middle.

CSF Leaks

• Suspect CSF leaks with head injuries. Check the halo test for CSF.
• Avoid applying pressure if CSF is leaking.

Ear Anatomy and Injuries

• The outer ear is called the pinna, with the tragus being the small flap in front.
• The external auditory canal is the start of the ear canal.
• The ear is divided into the external, middle, and inner ear.
• The external ear includes the pinna, external auditory canal, and tympanic membrane.
• The middle ear contains the malleus (hammer), incus (anvil), and stapes (stirrup).
• The inner ear (cochlea) is essential for hearing and balance.
• Vertigo is often associated with inner ear problems.
• Injured ears don't bleed much. If avulsed, place in a moist sterile dressing in a plastic bag, and transport to a specialty center.
• Tympanic membrane rupture can be caused by pressure changes, often painless, but results in hearing issues and ringing in the ear.

Foreign Objects

• Do not remove foreign objects from the ear canal.
• Clear fluid coming from the ear may be CSF.

Facial Fractures

• Facial fractures often result from blunt trauma. Suspect fractures for direct blows to the mouth or nose. Symptoms include bleeding in the mouth, inability to swallow or talk, absent/loose teeth, and movable bone fragments.
• The fractures themselves are often not critical but can be due to serious bleeding. Airway can be compromised.

Dental Injuries

• Remove any dental fragments that could compromise the airway.
• Save and transport avulsed teeth in sterile saline or chilled milk. Reimplanation is ideally done within 20 minutes to 1 hour afterward, but can be done up to 24 hours.

Impaled Cheek Objects

• Remove the impaled object on the cheek if it compromises the airway. Otherwise, provide direct pressure on both sides of the cheek.

Neck Injuries

• The neck contains the upper airway, esophagus, carotid arteries, jugular veins, thyroid cartilage, cricoid cartilage, and trachea.

Airway Management

• Airway management should be done aggressively given how the airways can be easily damaged, and one should call ALS early.

Subcutaneous Emphysema

• Upper airway injuries can result in loss of voice, difficulty swallowing, airway obstruction, and subcutaneous emphysema (air leakage into soft tissues, feeling like rice crispies).

Penetrating Injuries

• Penetrating injuries to the neck may damage major vessels. High-flow oxygen and spinal motion restrictions should be done for more severe injuries.

Laryngeal Injuries

• Laryngeal injuries are caused by blunt trauma and strangulation. Symptoms include respiratory distress, hoarseness, pain, dysphagia, cyanosis, pale skin, sputum in the wound, and subcutaneous emphysema.
• Immobilize the spine, give the patient oxygen, and call ALS.

Arteries and Veins

Arterial Damage: Hemorrhage

Venous Damage: Air Embolism

Exam Questions

• The Adam's apple is not inferior to the cricoid cartilage.
• The globe of the eye is also known as the eye
• Correct pupil dilation and constriction depends on amount of light and distance objects are focused on
• While it's important to care for the other eye, if any dangerous eye substances flow to the other eye, the patient should be laid on their affected side.
• Symmetric pupils would be least indicative of a head injury.
• Eustachian Tube Function: Equalize pressure in your middle ear when pressure changes
• If patients have facial trauma, the greater concern should be airway compromise.
• Subcutaneous Emphysema would be indicative of a crushed tracheal injury.
• When bright blood is spurting from the neck area, it should be immediately tended with a gloved hand applying pressure to the bleeding.
• Laryngeal or tracheal injuries are most caused by attempted suicide by hanging.
• Fluid near the back of the eye: Vitreous Humor
• This is a membrane that covers the eye: Sclera
• Glands that produce fluid to moisten eye: Lacrimal Glands
• Is used to classify nosebleeds: epistaxis
• If the soft contact lenses need to be removed, saline needs to be applied on both, then pinch lenses out gently.