34 Emergencies Involving the Eyes, Ears, Nose, and Throat

Objectives Review the epidemiology of facial injuries. Discuss pathophysiologic changes that occur with facial emergencies. Review pertinent questions and physical findings of facial injuries. Discuss proper use of Morgan Lens kit. Indentify proper prehospital treatment. Discuss the objectives.

Introduction Facial injuries can cause significant injuries and emotional stress. Airway patency is always a concern with trauma to the face. Associated injuries to the neck and spine may also occur. Facial injuries can result in life-threatening conditions. Associated injuries to the brain and spinal cord may occur as well. Assessment and management should focus on maintenance of the airway, breathing, and circulation functions.

Epidemiology Greater than 1 million facial injuries per year. 50% of high-impact fractures also have other major injuries. Associated cervical injury occurs up to 6% of the time. Although facial injuries can be life-threatening in and of themselves, they commonly occur with other body system trauma in high impact mechanisms.

Types of facial fractures

Common neck and throat injuries

Pathophysiology Dispersion of kinetic energy during deceleration produces the forces that result in injury. High impact force is defined as a force greater than 50 times the force of gravity. On the other hand, low impact force is less than 50 times the force of gravity. The zygoma (cheek) and nasal bone need only a low impact force to cause damage. The supraorbital rim of the eye, mandible (jaw), and frontal bones require a high impact force to cause injury. The most common of all facial fractures are simple nasal fractures.

Pathophysiology (cont’d) Eye injuries Irrigation may be necessary. Chemical burns require flushing >20 minutes. Alkali burns require flushing till arrival at hospital. Use of the Morgan Lens® is beneficial in flushing a patient's eye, especially during the prolonged irrigation of chemical burns. The Morgan Lens is a contact lens type irrigation device that provides slow, continuous eye irrigation. The lens itself is attached to intravenous tubing primed with saline or Ringer’s lactate. With a slow, steady flow, place the lens onto the patient's eye. Have the patient look downward and set the lens on the upper aspect of the eye and allow the lid to sit over the lens, look upward to facilitate the placement of the lens on the lower aspect of the eye. Allow the eyelid to cover the bottom aspect of the lens. The continuous flushing of fluid is effective in irrigating the eye.

Pathophysiology (cont’d) Epistaxis Anterior bleeding Posterior bleeding Control by pinching nostrils together for 10 minutes Once hemostasis is achieved, the timing, frequency, and severity of the epistaxis should be determined. Is this an isolated episode or one of many? Are there any medical conditions that can be exacerbated by blood loss? Examples of these conditions include: Coronary artery disease Chronic obstructive pulmonary disease Is the patient experiencing any signs or symptoms associated with these conditions, such as chest pain, dyspnea, weakness, or dizziness?

Controlling a nosebleed: Have the patient sit and lean forward.

Controlling a nosebleed: Pinch the fleshy part of the nostrils together.

Assessment Findings General assessment considerations Consider maintaining cervical spinal immobilization during assessment. Assess and treat any threats to ABCs first. Determine answers to specific questions regarding consciousness, vision problems, hearing problems, malocclusion of teeth, drainage from ears, or open neck trauma. Relate assessment findings back to pathophysiology.

Assessment Findings (cont’d) General findings History consistent with trauma Structural damage to facial structures Open hemorrhage and/or oral hemorrhage Punctures, penetrations, lacerations to head, face, or neck Pain to cervical vertebrae, possible neuromuscular deficits from cord injury Relate history findings back to pathophysiology.

Emergency Medical Care Take spinal precautions. Ensure airway, suction as needed. Provide oxygen based on need. Apply oxygen to keep SpO2 >95%. NRB or PPV based on breathing adequacy. Whether you are treating an injury to the eye, face, or neck, emergency care focuses on: Airway Breathing Circulation

Emergency Medical Care (cont’d) Control external hemorrhage as appropriate. Initiate transport Whether you are treating an injury to the eye, face, or neck, emergency care focuses on: Airway Breathing Circulation

Case Study You are called for a motor vehicle versus pedestrian incident on a busy city street. Upon arrival a crowd has gathered around a motionless victim lying supine in the road. At the patient's side, you see facial trauma with hemorrhaging, the right arm is abnormally angled, and breathing seems labored. Discuss the case study.

Case Study (cont’d) Scene Size-Up Scene is safe, controlled by PD. Standard precautions taken. Patient is 17 year old female, 120 lbs. Entry and egress from site is unobstructed. MOI is traumatic incident. No additional resources needed. Discuss the case study.

Case Study (cont’d) Primary Assessment Findings Patient unresponsive. Blood and broken teeth in airway. Breathing labored and tachypneic. Peripheral perfusion intact. Patient not responding to painful stimuli. Discuss the case study.

Case Study (cont’d) Is this patient a high or low priority? What kind of differentials for the unresponsiveness exist? What care should be initiated immediately? Patient is a high priority (unstable) due to the unresponsiveness and partial airway occlusion. Differentials for the unresponsiveness include: Hypoxia from airway occlusion and inadequate breathing Possible volume loss causing poor brain perfusion The patient may have a traumatic brain injury The patient should have cervical spine manually stabilized. The airway should be suctioned of blood and the broken teeth removed. The airway should be maintained with a manual technique. PPV will be based upon breathing adequacy once reassessed following airway opening. Finally, direct pressure should be applied to any major hemorrhage.

Case Study (cont’d) Medical History Medications Allergies Unknown Discuss the case progression.

Case Study (cont’d) Pertinent Secondary Assessment Findings Pupils equal but sluggish to respond. Airway established by EMS, now patent. Perfusion intact peripherally, pulse rapid. Breathing spontaneously adequate. No major bleeds to the body. Discuss the case progression.

Case Study (cont’d) Pertinent Secondary Assessment Findings (continued) Right arm angulation to be managed by back board. SpO2 95% on room air, 99% on oxygen. No further findings contributory to this report. Discuss the case progression.

Case Study (cont’d) Care provided: Patient fully immobilized. Airway maintained with suctioning and manual technique. Oxygen via NRB mask with adequate breathing. Review treatment. Stress that maintenance of the airway due to the facial injury was paramount in the overall survival of this patient.

Case Study (cont’d) Care provided: Arm angulation immobilized by back board. Transport initiated to ED with Paramedic intercept planned en route. Review treatment. Stress that maintenance of the airway due to the facial injury was paramount in the overall survival of this patient.

Summary Facial injuries can result in life-threatening conditions. Associated injuries to the brain and spinal cord may occur as well. Assessment and management should focus on maintenance of the airway, breathing, and circulation functions. Review as appropriate.