Chapter26

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					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.
                                   You are the provider

• Priority transport                    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.

				
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