26: Face and Throat Injuries

Cognitive Objectives

(1 of 2)

1. Describe the causes of upper airway obstructions in facial injuries.

2. List the steps in the emergency medical care of the patient with soft-tissue wounds of the face and neck.

3. List the steps in the emergency medical care of the patient with injuries of the nose and ear.

4. List the physical findings of a patient with a facial fracture.

Cognitive Objectives

(2 of 2)

5. List the steps in the emergency medical care of the patient with a penetrating injury to the neck.

6. List the steps in the emergency medical care of the patient with an upper airway injury.

7. List the steps in the emergency medical care of the patient with dental injuries.

• There are no affective objectives for this chapter.

Psychomotor Objectives

8. Demonstrate the care of a patient with soft-tissue wounds of the face and neck. 9. Demonstrate the care of a patient with injuries of the nose and ear. 10. Demonstrate the care of a patient with a penetrating injury to the neck.

11. Demonstrate the care of a patient with an upper airway injury. • 12. Demonstrate the care of a patient with dental injuries.

All of the objectives in this chapter are noncurriculum objectives.

Anatomy of the Head

Landmarks of the Neck

Injuries to the Face

• Injuries about the face can lead to upper airway obstructions.

• Bleeding from the face can be profuse.

• Loosened teeth may lodge in the throat.

• If the great vessels are injured, significant bleeding and pressure may occur.

Soft-Tissue Injuries

• Soft-tissue injuries to the face and scalp are common.

• Wounds to the face and scalp bleed profusely.

• A blunt injury may lead to a hematoma.

• Sometimes a flap of skin is peeled back from the underlying muscle.

Hematoma

• Blunt injury that does not break the skin may cause a break in a blood vessel wall.

• You and your EMT-B partner receive a call to the Acme Barn on a report of a fight. • On arrival, law enforcement personnel advise you that the scene is safe and that they have the suspect. • You take BSI precautions and approach a 25-year old man holding his neck. You ask what happened. He replies that he was stabbed.

You are the provider

• What are your safety considerations at the scene?

• What was the mechanism of injury?

You are the provider continued

Scene Size up

• Take BSI precautions. • Patients with facial bleeding may cough, projecting blood.

• Place several pairs of gloves in pocket.

• Look for bleeding as you approach.

• Consider spinal immobilization.

• You ask the patient his name; he responds “Bill.” • You observe blood flowing freely under his hand. • He is breathing rapidly.

• You find a puncture wound to the right side of his neck with profuse, bright red bleeding.

You are the provider continued (1 of 2)

• What are the steps of your initial assessment?

• When do you control the bleeding?

• How would you control the bleeding?

• What is your transport decision?

• Would you call for ALS backup?

You are the provider continued (2 of 2)

• What are other treatment considerations?

Initial Assessment

• Maintain patient airway.

• Do not insert nasopharyngeal airway if there is chance of basal skull fracture.

• Quickly assess chest for DCAP-BTLS.

• Place nonrebreathing mask over facial injuries; may be difficult but is important.

• Quickly assess pulse.

• Control life-threatening bleeding.

Transport Decision

• Avoid delays in transport.

• Consider ALS backup for long transport times.

• Monitor constantly.

• Significant blow to face or throat may mean spinal or brain injury.

• You ensure that his airway is open, taking c-spine precautions. • No noted airway abnormalities. Breathing is rapid.

• DCAP-BTLS is unremarkable. • You control neck bleeding with sterile dressing and direct pressure; color is bright red, suggestive of arterial bleeding. • You start oxygen via nonrebreathing mask at 10-15 L/min.

• Priority transport

You are the provider continued

Focused History and Physical Exam

• Rapid physical exam or focused physical exam depending on injury • Use DCAP-BTLS to guide you to identify and correct threats to life.

• Do not focus only on bleeding.

• Obtain baseline vital signs and SAMPLE history.

Interventions

• Complete spinal immobilization if spinal injuries suspected.

• Maintain open airway.

• Provide high-flow oxygen.

• May need assisted ventilation with BVM device • Control bleeding.

• Treat for shock if patient has signs of hypoperfusion.

• Do not delay transport.

Detailed Physical Exam

• Perform if patient is stable and time allows.

Ongoing Assessment

• Reassessment is particularly important with face and throat injuries.

• These can easily affect respiratory, cardiovascular, and nervous systems.

• Communication and documentation – Include description of MOI.

– Estimate amount of blood loss.

– Note specific injuries.

• You must transport rapidly to a trauma center.

• If direct pressure does not control bleeding, apply pressure above and below wound. • Secure dressing with bandage over wound and wrap it under patient’s arm.

• Maintain cervical immobilization. • Apply pressure to wound en route to trauma center.

You are the provider continued

Care of Soft-Tissue Injuries

(1 of 3)

• Assess the ABCs and care for life-threatening injuries.

• Follow proper BSI precautions.

• Blood draining into the throat can lead to vomiting. Monitor airway constantly.

• Take appropriate precautions if you suspect a neck injury.

Care of Soft-Tissue Injuries

(2 of 3)

• Control bleeding by applying direct pressure.

Care of Soft-Tissue Injuries

(3 of 3)

• Injuries around the mouth may obstruct the airway.

Injuries of the Nose

• Blunt trauma to the nose can result in fractures and soft-tissue injuries.

• Cerebrospinal fluid coming from the nose is indicative of a basal skull fracture.

• Bleeding from soft-tissue injuries of the nose can be controlled with a dressing.

Injuries of the Ear

• Ear injuries do not usually bleed much.

• Place a dressing between the ear and scalp when bandaging the ear.

• For an avulsed ear, wrap the part in a moist sterile dressing.

• If a foreign body is lodged in the ear, do not try to manipulate it.

Facial Fractures

• A direct blow to the mouth or nose can result in a facial fracture.

• Severe bleeding in the mouth, loose teeth, or movable bone fragments indicate a break.

• Fractures around the face and mouth can produce deformities.

• Severe swelling may obstruct the airway.

Dislodged Teeth

• Dislodged teeth should be transported with the patient in a container with some of the patient’s saliva or with some milk to preserve them.

Blunt Injuries of the Neck

• A crushing injury of the neck may involve the larynx or trachea.

• A fracture to these structures can lead to subcutaneous emphysema.

• Be aware of complete airway obstruction and the need for rapid transport to the hospital.

Penetrating Injuries of the Neck

(1 of 2)

• They can cause severe bleeding.

• The airway, esophagus, and spinal cord can be damaged from penetrating injuries.

• Apply direct pressure to control bleeding.

• Place an occlusive dressing on a neck wound.

Penetrating Injuries of the Neck

(2 of 2)

• Secure the dressing in place with roller gauze, adding more dressing if needed.

• Wrap gauze around and under patient’s shoulder.

Review

1. When caring for a patient with facial trauma, the EMT-B should be MOST concerned with: A. spinal trauma.

B. airway compromise.

C. associated eye injuries.

D. severe external bleeding.

Review

Answer: B Rationale: No airway, no patient! Injuries to the face often cause obstruction of the upper airway, either by clotted blood or associated swelling. Additionally, large amounts of blood can be swallowed, which increases the risks of vomiting and aspiration. Bleeding control, spinal trauma, and associated injuries are important factors and should be treated accordingly; however, the airway comes first.

Review

1.

When caring for a patient with facial trauma, the EMT-B should be MOST concerned with: A. spinal trauma.

Rationale: This is a concern to be treated, but treating the airway is first.

B. airway compromise.

Rationale: Correct answer C. associated eye injuries.

Rationale: This is a concern to be treated, but treating the airway is first.

D. severe external bleeding. Rationale: This is a concern to be treated, but treating the airway is first.

Review

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

A. Attempted suicide by hanging B. Gunshot wound to the lateral neck C. Car crash involving lateral impact D. Patient whose head hits the windshield

Review

Answer: A Rationale: Any crushing injury of the upper part of the neck is likely to involve the larynx or trachea. Examples include the anterior neck impacting a steering wheel, hanging (distraction) mechanisms, and clothesline injuries.

Review

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

A. Attempted suicide by hanging Rationale: Correct answer B. Gunshot wound to the lateral neck Rationale: This would produce a penetrating injury.

C. Car crash involving lateral impact Rationale: This would produce an injury to the spine and possibly the head.

D. Patient whose head hits the windshield Rationale: This would produce an injury to the head or a compression injury to the spine.

Review

3. A 39-year-old man was struck in the face and has a partially avulsed nose. After taking BSI precautions, you should: A. apply oxygen if it is indicated.

B. cover the injury with a sterile dressing.

C. instruct the patient to tilt his head back.

D. assess the status of his airway and breathing.

Review

Answer: D Rationale: After taking appropriate BSI precautions, initial care for any facial injury involves assessing the status of the patient’s airway and breathing. Facial injuries are often associated with oral bleeding, which can compromise the airway. Instruct the patient to lean forward to prevent drainage of blood down the back of the throat, and cover the injury with a sterile dressing.

Review

3. A 39-year-old man was struck in the face and has a partially avulsed nose. After taking BSI precautions, you should: A. apply oxygen if it is indicated.

Rationale: Airway management is the first priority after BSI.

B. cover the injury with a sterile dressing.

Rationale: This is part of bleeding control after airway management.

C. instruct the patient to tilt his head back.

Rationale: Do not tilt the patient’s head back. Blood will drain into the throat and stomach which may cause vomiting and airway compromise.

D. assess the status of his airway and breathing.

Rationale: Correct answer

Review

4. The presence of subcutaneous emphysema following trauma to the face and throat is MOST suggestive of: A. esophageal injury.

B. cervical spine fracture.

C. crushing tracheal injury.

D. carotid artery laceration.

Review

Answer: C Rationale: Crushing injuries or fractures of the larynx or trachea can result in a leakage of air into the soft tissues of the neck. The presence of air in the soft tissues produces a characteristic crackling sensation called subcutaneous emphysema.

Review

4. The presence of subcutaneous emphysema following trauma to the face and throat is MOST suggestive of: A. esophageal injury.

Rationale: This will produce bleeding, which may be observed in the patient’s mouth or through difficulty swallowing.

B. cervical spine fracture.

Rationale: This may be indicated by pain and/or paralysis.

C. crushing tracheal injury.

Rationale: Correct answer D. carotid artery laceration. Rationale: This could be assessed by excessive swelling or the presence of a large hematoma in the neck area.

Review

5. Which of the following statements regarding the “Adam's apple” is FALSE?

A. It is inferior to the cricoid cartilage B. It is formed by the thyroid cartilage C. It is the uppermost part of the larynx D. It is more prominent in men than in women.

Review

Answer: A Rationale: The most obvious prominence in the center of the anterior neck is the Adam's apple. This prominence is the upper part of the larynx, formed by the thyroid cartilage. It is more prominent in men than in women. The other portion of the larynx is the cricoid cartilage, a firm ridge that is inferior to the thyroid cartilage.

Review

5. Which of the following statements regarding the “Adam's apple” is FALSE?

A. It is inferior to the cricoid cartilage Rationale: Correct answer. B. It is formed by the thyroid cartilage Rationale: This is true.

C. It is the uppermost part of the larynx Rationale: This is true.

D. It is more prominent in men than in women.

Rationale: This is true.

Review

6. 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: A. apply a pressure dressing to his neck.

B. sit the patient up to slow the bleeding.

C. place your gloved hand over the wound.

D. apply 100% oxygen via nonrebreathing mask.

Review

Answer: C Rationale: Laceration of the carotid artery —as evidenced by bright red blood spurting from the wound —can cause profuse bleeding, profound shock, and death very quickly. You must

immediately

control the bleeding with the use of direct pressure. Cover the wound with your gloved hand initially and then apply a bulky pressure dressing. After the bleeding has been controlled, apply high-flow oxygen and transport promptly.

Review

6. 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: A. apply a pressure dressing to his neck.

Rationale: You should apply a bulky dressing to control bleeding.

B. sit the patient up to slow the bleeding.

Rationale: Bleeding must be controlled first with direct pressure.

C. place your gloved hand over the wound.

Rationale: Correct answer D. apply 100% oxygen via nonrebreathing mask.

Rationale: A nonrebreathing mask is applied after bleeding is controlled.

Review

7. In addition to severe external bleeding, the MOST immediate concern for a patient who has a large laceration of the jugular vein is: A. an air embolism.

B. airway compromise.

C. associated tracheal injury. D. a life-threatening infection.

Review

Answer: A Rationale: If a vein has been opened, especially the large jugular veins of the neck, air can be sucked through it to the heart, resulting in an air embolism. A large volume of air in the right atrium and right ventricle can lead to cardiac arrest.

Review

7. In addition to severe external bleeding, the MOST immediate concern for a patient who has a large laceration of the jugular vein is: A. an air embolism.

Rationale: Correct answer B. airway compromise.

Rationale: This must be evaluated.

C. associated tracheal injury. Rationale: This must be evaluated.

D. a life-threatening infection.

Rationale: This is not an immediate life threat in the field. It is a possible problem that may be seen in the hospital setting.

Review

8. Signs of a mandibular fracture include all of the following, EXCEPT: A. loose or dislodged teeth.

B. bleeding in the oral cavity.

C. inability to swallow or talk.

D. bruising over the mastoid bone.

Review

Answer: D Rationale: Signs of a mandibular (lower jawbone) fracture include loose or dislodged teeth, bleeding into the oral cavity (mouth), an irregular bite (malocclusion), and an inability to swallow or talk. Bruising over the mastoid bone behind the ear (Battle’s sign) is indicative of a basilar skull fracture.

Review

8. Signs of a mandibular fracture include all of the following, EXCEPT: A. loose or dislodged teeth.

Rationale: This can be an assessment finding with a jaw fracture.

B. bleeding in the oral cavity.

Rationale: This can be an assessment finding with a jaw fracture.

C. inability to swallow or talk.

Rationale: This can be an assessment finding with a jaw fracture.

D. bruising over the mastoid bone.

Rationale: Correct answer

Review

9. The nasopharyngeal airway is contraindicated in patients with: A. oropharyngeal bleeding.

B. a basilar skull fracture. C. a large facial hematoma. D. missing or dislodged teeth.

Review

Answer: B Rationale: The nasopharyngeal (nasal) airway should be avoided in patients suspected of having a skull fracture —specifically basilar or midface fractures. If a midface fracture is present, the nasal airway could potentially enter the cranial vault and penetrate the brain during insertion. Nasal airways are also contraindicated in patients with nasal fractures and in those with fluid drainage from the nose following head or face trauma.

Review

9. The nasopharyngeal airway is contraindicated in patients with: A. oropharyngeal bleeding.

Rationale: If the patient is bleeding in the back of the throat, a nasal airway may provide a route for suctioning, using a French catheter.

B. a basilar skull fracture. Rationale: Correct answer C. a large facial hematoma. Rationale: You can use a nasopharyngeal airway if a midface fracture is not suspected.

D. missing or dislodged teeth. Rationale: This will not interfere with the use of a nasopharyngeal airway.

Review

10. The purpose of the eustachian tube is to: A. move in response to sound waves.

B. transmit impulses from the brain to the ear.

C. equalize pressure in the middle ear when external pressure changes.

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

Review

Answer: C Rationale: The middle ear is connected to the nasal cavity by the eustachian tube, which permits equalization of pressure in the middle ear when external atmospheric pressure changes.

Review

10. The purpose of the eustachian tube is to: A. move in response to sound waves.

Rationale: This occurs in the tympanic membrane or eardrum.

B. transmit impulses from the brain to the ear.

Rationale: Impulses are transmitted from the ear to the brain.

C. equalize pressure in the middle ear when external pressure changes.

Rationale: Correct answer D. house fluid within the inner chamber of the ear and support balance.

Rationale: Boney chambers in the inner ear support balance.