Head & Face Emergencies

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Introduction

Management of head and facial trauma in the pre-hospital environment can be quite difficult. Facial trauma can be very disfiguring and grotesque in nature and accompanied with severe hemorrhaging. This, coupled with the immense anxiety which the patient may demonstrate, can be extremely frustrating. By performing an organized primary and secondary survey and performing appropriate interventions you can help to alleviate the pain and anxiety the victim may feel. It will also allow you to stay focused on the total patient rather than having "tunnel vision" on one particular body region.

This lesson is intended to provide basic and expanded information for the treatment of head and facial trauma. Injuries to the brain and other central nervous system components are not addressed in this lesson. The lesson entitled "Injuries to the CNS" covers these topics.

Anatomy

The Skull

There are several bony structures which provide the framework of the head and face. The skull is divided into two general regions, the cranium and the face. The cranial vault is protected by the frontal bone which is commonly referred to as the forehead. The temporal bones make up the areas that we refer to as the temples. Posteriorly and superiorly to the temples are the parietal bones. These parietal bones are located above the ear and meet in the midline suture at the superior portion of the skull. Protecting the posterior aspect of the cranial vault is the occipital bone.

The structures which make up the orbit, or the eye "socket", are as follows:

  • maxilla and zygomatic bones make up the base of the socket
  • ethmoid bones are located medially and posteriorly in the socket
  • frontal bones make up the roof of the eye socket
  • sphenoid bones are located posteriorly in the socket.

The cheeks are made up of the zygomatic bones and maxilla. The maxilla also make up the bridge of the upper mouth and teeth. The teeth are inserted into the maxilla and the mandible in immovable joints called alveoli. The nose is made up of the nasal bones and cartilaginous concha. The nasal cartilage defines the shape of the nose. The lower jaw is called the mandible which attaches to the skull at the temporomandibular joint. Other than the ossicles in the middle ear, the mandible is the only movable bone in the skull.

There are several paired cavities within the bones of the skull called paranasal sinuses. These sinuses are located in the frontal, sphenoid, maxilla, and ethmoid bones. They are lined with mucous membranes. These sinuses can be damaged by blunt or penetrating trauma to the face.

Covering these bony structures is connective tissue called fascia and muscles attached by tendinous sheaths. Scalp and facial skin overly these structures. There is a rich blood supply to facial muscles as well as the skin itself. Even minor breaks in the skin integrity may lead to significant bleeding especially in pediatric patients.

The Eyes

The eyes are divided into three layers, the fibrous tunic, the vascular tunic, and the nervous tunic.

The fibrous tunic is the superficial coat of the eyeball which consists of the sclera and the cornea. The sclera is the "white" of the eye that covers all of the eyeball except the cornea. It gives shape and rigidity to the eyeball and provides protection for the inner parts of the eye. The cornea is a nonvascular, transparent coat that covers the iris. It is curved and helps focus light entering the eye.

The vascular tunic, or uvea, is the middle layer of the eyeball that contains the choroid, the ciliary body, and the iris. The choroid is the posterior portion that lines the inner surface of the sclera. It is highly vascular and provides nutrients to the retina. The ciliary body is the anterior portion of the vascular tunic. It functions in secretion of the aqueous humor and the ciliary muscle alters the shape of the lens. The iris is the colored portion of the eyeball that is suspended between the cornea and the lens. It is composed of muscle that constricts and dilates to regulate the amount of light that enters the eye. The hole in the middle of the iris is called the pupil.

The nervous tunic, or the retina, is the inner, posterior coat of the eyeball. The retina contains photo receptors, the rods and cones. The rods sense shades of gray in dim light and also sense shapes and movement. The cones function in bright light and are responsible for sensing colors. The optic disc is where the optic nerve exits the eyeball. No rods or cones are located in the optic disc, therefore it is also known as the "blind spot".

The lens is located posterior to the pupil and is responsible for focusing light rays for clear vision. The interior of the eyeball consists of the anterior cavity, which is divided into the anterior chamber and the posterior chamber. The anterior cavity is the space just anterior to the lens and is filled with aqueous humor which nourishes the lens and cornea. The posterior cavity is also known as the vitreous chamber. It is located between the lens and the retina and is filled with the jellylike vitreous body, or vitreous humor. The vitreous humor is responsible for the eye's spherical shape.

The eyes are protected by the eyelids, or palpebrae. The eyelids protect the eyes from excessive light and foreign objects, shade the eyes during sleep, and spread lubricating secretions over the eyeballs. Lacrimal fluid, or tears, is produced by the lacrimal glands. Tears function in lubricating and cleaning the eyeball. The inner surface of the eyelids is composed of a mucous membrane called the conjunctiva. The eyelashes protect the eye from foreign objects, perspiration, and light.

The Ears

The ears are divided into three sections, the outer (external) ear, the middle ear, and the inner ear.

The visible portion of the outer ear is called the auricle, or pinna. The auricle is a flap of elastic cartilage covered by skin. It is "trumpet" shaped to help collect sound waves. The external auditory canal is a curved tube in the temporal bone that extends from the the auricle to the eardrum. It directs sound waves to the eardrum. The canal is lined with hairs and ceruminous glands that secrete cerumen, or earwax, that helps prevent dust and other foreign objects from entering the ear. The tympanic membrane, or eardrum, is the semitransparent partition between the external auditory canal the the middle ear. It vibrates with sound waves and transmits these vibrations to the middle ear.

The middle ear, or tympanic cavity, is an air filled cavity in the temporal bone. It contains the auditory ossicles: the malleus, incus, and stapes. These tiny bones transmit and amplify vibrations to the inner ear. The Eustachian tube connects the middle ear to the nasopharynx. It functions in equalizing air pressure in the middle ear.

The inner ear, or labyrinth, contains the semicircular canals and the cochlea. The three semicircular canals function in maintaining balance and equilibrium. The cochlea contains receptors for hearing. The vestibulocochlear nerve (Cranial Nerve VIII) conducts auditory impulses to the brain.

Types of Injuries

Blunt and Penetrating Trauma

Injuries to the face and head may be caused by many forces. Blunt and penetrating trauma may lead to significant injury. Common forms of blunt trauma would consist of facial impacts on windshields or pavement. Assaults may lead to significant facial trauma. Penetrating wounds may occur secondary to knife or other stabbing objects as well as gunshot wounds to the face or head.

Treatment for victims with head and facial trauma include management of the system involved as well as potential airway complications. There is also significant risk of Central Nervous System (CNS) injury.

Patients who present with blunt trauma require a systematic and organized primary survey followed by a detailed head to toe exam.

Visualization and palpation of the cranium is necessary to locate sources of bleeding as well as potential bony fractures. This palpation is done gently to assess for pain or deformities. Overzealous palpation of a skull fracture may lead to inadvertent displacement of bony fragments. Common fractures seen include mandibular, maxillary and zygomatic. One may also suffer "linear" as well as depressed skull fractures. Bony fractures of the cranium and face cannot be splinted in place. Their pre-hospital treatment requires only assessment and monitoring unless they interfere with airway control.

If the patient's airway is compromised by fractures of the maxilla or mandible then gentle displacement should not be delayed.

Maxillary fractures are often classified as Le Fort I, Le Fort II, or Le Fort III fractures. A Le Fort I fracture is a fracture of only the maxilla at the level of the nasal fossa (opening). A Le Fort II fracture, or a pyramidal dysfunction, involves the maxilla, the nasal bones, and the medial aspects of the orbits. A Le Fort III fracture, or craniofacial dysfunction, involves the maxilla, the zygoma (cheek bone), the nasal bones, the ethmoids, and smaller bones of the cranial base. All of these fractures will probably be accompanied by nose bleeding (epistaxis) and Le Fort II and III fractures may be accompanied by CSF drainage. Be alert for airway compromise in these patients.

Blunt or penetrating trauma may cause nasal injuries. Bleeding from the nose (epistaxis) may occur, which can compromise the airway. Monitor the airway closely and have suction available. Nasal injuries may be accompanied by underlying injuries, such as fractures to the sphenoid or ethmoid bones. Cerebrospinal fluid draining from the nose may indicate a basilar skull fracture.

Injuries to the mouth can cause airway compromise due to excessive bleeding, foreign objects such as teeth in the airway, or damage to internal structures such as the tongue. The mucous membranes and the tongue are highly vascular and may exhibit copious bleeding from trauma to these structures. Patients may also suffer an avulsion of their teeth. You should prevent aspiration of blood by appropriate positioning of the patient and early utilization of suction devices. You should attempt to locate the victim's teeth, if possible, and wrap them in a 4 x 4 moistened with sterile normal saline. These should be transported with the patient as re-implantation may be possible. Contact your area oral surgeons in regard to their preparation preferences for avulsed teeth, as this may differ from region to region.

Lacerations

Treatment for patients with facial or scalp lacerations should include hemorrhage control with direct pressure or bulky absorbent dressing application. Remember that a laceration may involve an underlying bony fracture.

Bloody or clear discharge from the ears or nose may indicate a basilar skull fracture. This hemorrhage should not be prevented. It is acceptable to place a sterile 4 x 4 over the ear or nares, but do not pack the orifice. Mechanical obstruction of this blood may result in significant increase in intracranial pressure.

A 4 x 4 tip may also be used to "catch" a drop of blood from the ears or nares to assess for a "Halo" effect. As the blood is soaked up with the absorbency of the 4 x 4 you may be able to detect a yellowish ring around the blood caused by the increased absorbency of cerebrospinal fluid (CSF). It should be noted however, that this is not a definitive diagnostic exam. The presence of the yellow halo does not confirm the presence of CSF nor does its absence rule out the presence of CSF.

Injuries to the ear can cause several problems. Laceration of the auricle, which does not have a good blood supply, can lead to infection and poor healing. If a section of the ear cartilage is separated from the ear, gently align the section into position and bandage in place with plenty of padding. Transport an ampuated section as you would an amputated extremity: wrap it in moist, sterile dressings and keep it cool but do not place the amputated section directly on ice. Blunt trauma to the ear, blast injuries, and pressure injuries (barotrauma) from diving can all cause rupture of the eardrum and subsequent damage to the delicate internal structures of the ear.

Pre-hospital treatment of victims with head and facial trauma should be as follows:

  • Assess patient with cervical spine precautions
  • Administer oxygen
  • Perform endotracheal intubation if the patient is unable to protect their own airway or a Glasgow Coma Score (GCS) < or = 8. (refer to the chart at the end of this lesson)
  • Nasotracheal intubation is contraindicated if facial bones are unstable. Orotracheal intubation or Rapid Sequence Induction (RSI)* should be performed
  • Control hemorrhage with direct pressure
  • Apply spinal motion restriction devices
  • Treat for shock
  • Suction airway as necessary
  • Rapid, safe transport to hospital
  • Initiate ECG monitoring and IV access at KVO rate
  • Notification of medical control and/or receiving hospital.

* Rapid Sequence Induction involves the use of paralytic agents prior to intubating a patient. This procedure is useful for patients that are combative or conscious patients that are unable to control their airway and nasotracheal intubation is not possible. Paralytic agents, such as succinylcholine (Anectine), paralyze all of the muscles in the body except the heart. The patient will stop breathing, so intubation is necessary. Even though the patient is paralyzed, they will still be aware of what is happening around him, so the use of sedatives such as diazepam (Valium) or midazolam (Versed) should be utilized. Succinylcholine is a short-acting paralytic agent that is usually used prior to intubation, so once the patient is intubated you should administer a longer acting agent such as vecuronium or pancuronium. Check your local protocols.

Impaled Objects

Impaled objects can appear very frightening when they are located in the face or cranium. These objects can damage vital structures within the head. Impaled objects should not be removed in the pre-hospital environment unless they are isolated to the tissue part of the cheek. These are removed only on the basis that they may bleed severely, and may interfere with airway control and involve no major structure that the rescuer could severely injure during removal. All other impaled objects should be immobilized in location found.

Eye Injuries

Injuries involving the eyes can be permanently debilitating. The eyes may be injured secondary to blunt or penetrating trauma, chemical exposure, or thermal burns from fire, hot gases or steam, welding burns, or even the sun. Any injury to the eyes may lead to visual disturbances or blindness. Laceration of the globe may lead to leaking of the vitreous humor. This is a fluid that we have no replacement for. The eyelid may also be lacerated or avulsed. Blunt trauma may cause retinal detachment.

Chemical exposure or thermal injury to the eyes should be treated immediately with irrigation. Normal saline is the irrigation solution of choice but if not available then tap water should be used. The irrigation should be continued for a minimum of 10 to 15 minutes. If pain persists after this time, then irrigation should be continued. Irrigation of eye injuries is one of the few times in pre-hospital medicine that it is actually acceptable to delay transport due to treatment. If possible, irrigation should be performed en route.

Some services utilize an instrument called the Morgan Eye Lens for irrigation of the eyes. This device is inserted in a fashion similar to a contact lens and is connected to IV tubing running normal saline. This device works well but may only be ordered by the physician.

Laceration or blunt trauma to the eyes should be treated with appropriate dressing and bandaging procedures. Bulky 4 x 4's or eye pads should be placed over both eyes even if both were not affected. These bandages should be secured in place with roller gauze or tape. When both eyes are bandaged in this manner it will limit the patient from moving their "good" eye. By reducing the movement of one eye you limit movement of the injured eye as well.

Penetrating objects that are impaled in the eye should be immobilized in position found. This can be accomplished with paper cups, 4 x 4's and roller gauze. Both eyes should be covered for this emergency as well.

Patients with injuries to their eyes depend on you for their sight. This is true for both long term and immediate visual needs. Remember to talk with your patient and explain what is happening. Verbal reassurance can reduce anxiety caused by loss of this sense.

Summary

Management of trauma victims with head and facial injuries can be very rewarding. By keeping wounds clean and providing control of hemorrhage you become an integral part of the patient's care. Your interventions may be just as important as the plastic surgeon who sutures the wound or the ophthalmologist who repairs the eye.

Glasgow Coma Score (Adult)

EYE OPENING RESPONSE:

Spontaneous        = 4

To Verbal Stimuli  = 3

To Painful Stimuli = 2

No Response       = 1

BEST VERBAL RESPONSE:

Oriented                               = 5

Confused                             = 4

Inappropriate Words            = 3

Incomprehensible Sounds   = 2

No Response                      = 1

BEST MOTOR RESPONSE:

Obeys Commands                             = 6

Localizes Pain                                   = 5

Withdraws from Pain                         = 4

Flexion (decorticate posturing)          = 3

Extension (decerebrate posturing)    = 2

No Response                                    = 1