The head is divided into two parts: the cranium and the face. The cranium, or skull, contains the brain and connects to the spinal cord through the foramen magnum. The most posterior portion of the cranium is called the occiput. The lateral portions are called the temples or temporal regions. Just between the occiput and the temporal regions lie the parietal regions. The forehead is called the frontal region. In the temporal region, you can feel the pulse of the superficial temporal artery.
The face is composed of six bones: the nasal bone, two maxillae (upper jaw), two zygomas (cheek bones), and one lower bone, the mandible. Motion of the mandible occurs at the temporomandibular joint. The orbit is composed of the lower edge of the frontal bone, the zygoma, the maxilla, and the nasal bone. The external visible part of the ear is called the pinna. The tragus is a small, rounded, fleshy bulge immediately anterior to the ear canal. Posterior to the external opening of the ear is a prominent bony mass at the base of the skull called the mastoid process.
The neck also contains many important structures. It is supported by the cervical spine. The cervical spine is the first seven vertebrae in the spinal column, which exit from the foramen magnum. Carotid arteries are found on either side of the trachea, along with the jugular veins and several nerves. The Adam’s apple is the upper part of the larynx, formed by the thyroid cartilage. The other portion of the larynx is the cricoid cartilage, a firm ridge of cartilage. Below the cricoid cartilage in the midline is the cricothyroid membrane. This is a thin sheet of connective tissue (fascia) that joins the thyroid cartilage and cricoid cartilage. Lying immediately adjacent to the carotid arteries and several important nerves laterally are the sternocleidomastoid muscles. These muscles originate from the mastoid process of the cranium and insert into the medial border of each collarbone and the sternum at the base of the neck and allow movement of the head. The most prominent spine is the seventh cervical vertebra.
In an adult, more than 80% of the eye is protected by the orbit. The globe, or eyeball, keeps its shape as a result of the pressure of the fluid contained within its two chambers. The clear jelly-like fluid near the back of the eye is called the vitreous humor (posterior compartment). In front of the lens is a clear fluid called the aqueous humor. Penetrations of the eye can cause the aqueous humor to leak out, but with time the aqueous humor heals. The inner surface of the eyelids and the exposed surface of the eye itself are covered by a delicate membrane, the conjunctiva. They are kept moist by fluid produced by the lacrimal glands (tear glands). The white of the eye is called the sclera, which extends over the surface of the globe. On the front of the eye, the sclera is replaced by a clear, transparent membrane called the cornea, which allows light to enter the eye. A circular muscle called the iris, like a shutter, regulates the amount of light that enters the eye. The opening in the center of the iris, which allows light to move to the back of the eye, is called the pupil. When people are born with pupils that are not equal, it is called anisocoria. In unconscious patients, unequal pupil size indicates serious injury. Behind the iris is the lens, which focuses images on the light-sensitive area at the back of the globe called the retina. Within the retina are numerous nerve endings that respond to light by transmitting nerve impulses through the optic nerve to the brain. The impulses are interpreted as vision. The retina is nourished by a layer of blood vessels between it and the sclera at the back of the globe called the choroid. Retinal detachment occurs when the retina detaches from the underlying choroid and sclera, and the nerve endings are not nourished, causing the patient to experience blindness.
There are a number of factors that could cause upper airway obstruction following an injury to the face. Bleeding can produce large blood clots in the upper airway. These clots can lead to complete airway obstruction. Direct injuries to the nose and mouth, the larynx, and the trachea are often the source of significant bleeding and/or respiratory compromise; you may need to suction the airway if you are unable to control the bleeding. Injuries that loosen teeth can result in them becoming dislodged in the throat, and the swelling that follows often contributes to airway obstruction. If the great vessels in the neck are injured, significant bleeding and pressure on the upper airway are common; these can result in airway obstruction. Depending on the MOI, there may be a cervical spine injury.
Soft-tissue injuries are blunt injuries that do not break the skin but may cause a break in a blood vessel wall, causing blood to collect under the skin (hematoma). A flap of skin may be peeled back, or avulsed, from the underlying muscle and fascia. Mandible fractures are relatively common because of the prominence of the mandible itself. These fractures are second only to nasal fractures in frequency. If a patient has a mandible fracture, it is possible with significant force that there is also a cervical injury. Signs include misalignment of teeth, numbness of the chin, and an inability to open the mouth. Fractured and avulsed teeth are common following facial trauma. Teeth fragments can become an airway obstruction and should be removed from the patient’s mouth immediately.
For injuries to the face, you should assess XABC first, following standard precautions. Use the jaw-thrust maneuver if you suspect that the patient may have sustained a cervical spine injury. Remember, blood draining into the throat can produce vomiting and airway obstruction; therefore, frequent suctioning may be required. Once spinal motion restriction is achieved, you can tilt the patient or backboard to one side, allowing any blood or vomitus to drain out of the mouth rather than pool in the pharynx and obstruct the airway. Control bleeding by applying direct manual pressure with a dry, sterile dressing. Do not apply excessive pressure if there is a possibility of an underlying skull fracture.
When injury exposes the brain, eye, or other structures, cover the exposed part with a moist, sterile dressing to protect it from further damage. For injuries in which the skin is not broken, apply ice or a cold pack locally to help control swelling of bruised tissues. For soft-tissue injuries around the mouth, always check for bleeding inside the mouth. Broken teeth and lacerations to the tongue may cause profuse bleeding and obstruction of the upper airway. Often, the patient will swallow the blood from lacerations inside the mouth, so the hemorrhage may not be apparent. You should also inspect the inside of the mouth for bleeding and hidden injuries in patients who have sustained facial trauma.
Often, doctors will be able to graft a piece of avulsed skin back into the appropriate position. For this reason, if you find portions of avulsed skin that have become separated, wrap them in a sterile dressing, place them in a plastic bag, and keep them cool. Never place tissue directly on ice because freezing will cause damage. In many avulsion injuries, the skin will still be attached in a loose flap. Place the flap in a position as close to normal as possible and hold it in place with a dry, sterile dressing.
For injuries to the eyes, keep in mind the following. Large objects are prevented from penetrating the eye by the protective orbit that surrounds it. However, even moderately sized and smaller foreign objects can enter the eye, causing significant damage. When the conjunctiva becomes inflamed and red, it is a condition called conjunctivitis. Almost immediately, the eye begins to produce tears to flush out the object. There may be intense pain, and the patient may have difficulty keeping the eyelids open because the irritation is further aggravated by bright light.
If a foreign object is lying on the surface of the patient’s eye, you should use a normal saline solution to gently irrigate the eye. Always flush from the nose side of the eye toward the outside to avoid flushing material into the other eye. A foreign body will often leave a small abrasion; for this reason, it is always a good idea to transport the patient to the hospital for further assessment to ensure appropriate medical care to the affected eye. Irrigation will not wash out foreign bodies that are stuck to the cornea or lying under the upper eyelid.
To examine the undersurface of the upper eyelid, pull the lid upward and forward. If you spot a foreign object, remove it with a moist, sterile cotton-tipped applicator. Foreign bodies ranging in size from a pencil to a sliver of metal may be impaled in the eye. These objects must be removed by a physician. Our job is to stabilize the object and bandage it in place to support it. Cover the eye with a moist, sterile dressing, and then surround the object with an eye shield or doughnut-shaped collar made from roller gauze or a small gauze pack. Bandage both eyes to prevent them from moving together.
Chemical burns require immediate, constant flushing of the eye with water or a sterile saline irrigation solution. The goal is to direct the greatest amount of irrigation solution or water into the eye as gently as possible. You may have to force open the lids, which will allow you to control the flow. If only one eye is affected, it is important to keep the other eye from becoming contaminated. Be sure to flush from the inner corner of the affected eye toward the outside corner. Never flush from the outside corner inward. Continuously irrigate the eye for 20 minutes. Afterwards, apply a clean, dry dressing to cover the eye and transport the patient promptly to the hospital for further care. If it can be done in the ambulance, it should be done during transport to save time.
When there are lacerations to the eye, control bleeding with gentle manual pressure. If there is a laceration of the globe itself, apply no pressure to the eye. Compression can lead to loss of vision. Cover the injured eye with a protective metal eye shield, cup, or sterile dressing, and cover both eyes. Provide prompt transport. Do not attempt to reposition an eye displaced out of its socket. Cover both eyes and have the patient lie supine to prevent further loss of fluid from the eye.
A black eye is the result of bleeding into the tissue around the orbit or a severely damaged globe. A condition called hyphemia, which is characterized by bleeding into the anterior chamber of the eye, is common following blunt trauma to the eye. About 25% of hyphemia are associated with underlying globe injuries, which are serious. Cover the eye to protect it from further injury and transport the patient to the hospital for further medical evaluation.
When this injury is associated with displacement, it is sometimes referred to as a blowout fracture. Fragments of fractured bone can entrap some of the muscles that control eye movement, causing double vision. Any patient who reports double vision should be promptly transported to the emergency department. Protect the eye from further injury with a metal shield and cover both eyes to minimize movement on the injured side.
Retinal detachment is an injury that is often seen in sports. It is painless but produces flashing lights, specks, or floaters in the field of vision, as well as a cloud or shade over the patient’s vision. This injury requires prompt medical attention to preserve vision.
Following an eye injury, you should be alert for one pupil larger than the other, eyes not moving together or pointing in different directions, failure of the eyes to follow the movement of your finger as instructed, bleeding under the conjunctiva that obscures the sclera, or protrusion or bulging of one eye. If there is a foreign body within the globe, do not attempt to remove it. Use a clean cup or similar object to protect the area. If only one eye is injured, follow local protocols.
If the patient has severe swelling or a hematoma to the eyelid, do not attempt to force the eyelid open to examine the eye because this increases pressure. For contact lenses and artificial eyes, you should not attempt to remove them unless in the case of chemical burns, where chemicals can be trapped under the lens. To remove a hard lens, use a suction cup moistened with saline. For a soft lens, gently moisten and then pinch the lens.
Burned eyelids require special attention. You should cover both eyes with a sterile dressing moistened with sterile saline. You may apply eye shields over the dressing. Direct sun and laser burns can cause significant damage to the sensory cells. Retinal injuries caused by exposure to extremely bright light are generally not painful but may result in permanent vision damage. Severe conjunctivitis usually develops, with redness, swelling, and excessive tear production. You can ease the pain by covering each eye with a sterile, moist pad and an eye shield.
Nosebleeds (epistaxis) are a common problem and are mostly caused by digital trauma (picking the nose). Posterior nosebleeds are usually more severe because the patient swallows blood, leading to nausea and vomiting. Trauma to the face and skull that results in a basilar skull fracture can cause the posterior wall of the nasal cavity to become unstable. Do not attempt to place a nasopharyngeal airway in a patient with significant facial trauma or a suspected basilar skull fracture, as this is controversial.
Inside the nose, there are layers of bone called turbinates, which are covered with a moist lining. Both chambers have a superior turbinate, a middle turbinate, and an inferior turbinate. Do not delay transport if you see cerebrospinal fluid (CSF) or a halo sign. The patient should be placed in a sitting position, leaning forward and pinching their nostrils together for 10 to 15 minutes.
The ear is divided into three parts. The external ear is composed of the pinna, or auricle, which leads to the external auditory canal, which in turn leads to the tympanic membrane, or eardrum. The middle ear contains three bones: the hammer, anvil, and stirrup, which move in response to sound waves hitting the tympanic membrane. The middle ear is connected to the nasopharynx by the eustachian tube. This connection permits equalization of pressure in the middle ear when external atmospheric pressure changes. The inner ear is composed of bony chambers filled with fluid. In response to stimulation, fine nerve endings send impulses to the brain indicating the position of the head and the rate of change of position.
Ears are often injured, but they usually do not bleed very much. If local pressure does not control the bleeding, you can apply a roller dressing. You should place a soft, padded dressing between the back of the patient’s ear and the scalp. In the case of an ear avulsion, you should wrap the avulsed part in a dry, sterile dressing and place it in a plastic bag labeled with the patient’s name. Sudden changes in pressure created by a blast wave may rupture one or both tympanic membranes. Never try to manipulate a foreign body because you may push it further into the auditory canal and cause permanent damage to the tympanic membrane.
To care for patients who have suffered blunt or penetrating trauma, consider the following. Any injury to the neck is considered life-threatening. Once the cartilages of the upper airway and larynx are fractured, they do not return to their normal position. This type of fracture could lead to loss of voice. The presence of air in the soft tissues produces a characteristic crackling sensation called subcutaneous emphysema. Keep in mind that complete airway obstruction can develop rapidly in these patients as a result of swelling or bleeding into the underlying tissues. Spinal injury is also a concern; therefore, spinal motion restriction may be indicated.
Penetrating injuries can cause profuse bleeding from lacerations of the great vessels in the neck. Injuries to the carotid and jugular vessels can cause the body to bleed out, also known as exsanguination. When air enters these vessels, it is known as an air embolism. Apply direct pressure and a sterile occlusive dressing to ensure that air does not enter a vein.
Laryngeal injuries may occur when the larynx is crushed against the cervical spine, resulting in soft-tissue injury, fractures, and separation of the fascia that connects the thyroid and cricoid cartilage, such as in strangulation injuries. You should always suspect a possible cervical spine injury. Signs and symptoms of laryngeal injuries include respiratory distress, hoarseness, pain, difficulty swallowing (dysphagia), cyanosis, pale skin, sputum in the wound, subcutaneous emphysema, bruising on the neck, hematoma, or bleeding.
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