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The face and neck are vulnerable to injury due to their relatively unprotected position on the body. Injuries can range from soft tissue injuries to fractures, some of which can be life-threatening. The head is often the first part of the body to be impacted in accidents or during physical altercations. The neck contains important structures such as the jugular veins and carotid arteries, and any bleeding in this area should be immediately addressed. The skull is composed of various bones, including the weakest part known as the temporal region. The face consists of 14 bones, and the nose is primarily made of cartilage. The ear is composed of different parts, including the pinna and the tragus. The jaw and chin are formed by the mandible. The neck is supported by the cervical spine and contains structures such as the larynx and trachea. The eye is globe-shaped and protected by the orbital socket. It consists of various chambers and fluids, such as the aqueous humor and Face and neck injury Face and neck are vulnerable to injury, they're relatively unprotected position on the body. You've got this 12 to 15 pound bowling ball on a small stock of muscle and bone, right? And what is it? What hits the windshield first, what hits the header on the windshield first, what hits the steering wheel, what do people punch, what do you get hit with, it's always the head that gets, you know, whacked. Soft tissue injuries and fractures are common and vary in severity. Some injuries are life-threatening, things like penetrating trauma to the neck, like if you penetrate a jugular vein, a carotid artery, you bleed out for a minute, and open airway, an open injury can result in an air embolism. So I take this bottle of water, I open it and I pour it out, as the water comes out, what replaces it? Air. So if I rupture a jugular vein, which is the vein that returns blood to my superior vena cava, as the blood comes pouring out, what goes in? Air. It takes about 40 cc's of air to produce a life-threatening air embolism. If you have seen IV tubing, you go from the bag to the IV, that standard tubing is about 40 cc's of air. So that, if you push that into somebody, that would be enough air to cause a life-threatening injury. Okay. So 40 cc's of air is not a lot of air, so that's why one of those things, you have a life-threatening, any kind of bleeding in the neck, take a glove hand and put it over it. Heal it. And then you can put, remember the occlusive dressing we talked about with the patients with pneumothorax, we put the occlusive dressing, it's very sticky and it seals the wound, put it right on that. Seal that up. Stop that bleeding right away. You don't want any penetrating injury from the neck to the umbilicus. All the way around, circumferentially, gets an occlusive dressing. Cranium contains the brain, the most posterior portion is called the occiput, right here. Lateral portions of each side are called the temples. The bone is the temporal bone, and then the region where they combine is called the temporal region. It's the weakest part of the skull, and unfortunately it has the largest blood vessel going to the brain, the middle meningeal artery underneath it. Forehead is called the frontal region. Anterior to the ear, in the temporal region, you can feel the pulse of the superficial temporal artery, right there. You can actually feel it on both sides, and that kind of feeds part of your face. So, this is the frontal bone, the parietal bone, the occipital bone, the occiput, and then this is the temporal bone, and this is the temporal region, right here, which is a combination of the frontal, the parietal, the temporal, and the sphenoid. This is the sphenoid, right here. And that's the four bones of the skull, then you have 14 bones of the face. You have the nasal septum, and the concha, that cause those, produce those turbinates. You have the sphenoid, which is out here. You have the lacrimals, which are inside. You have the zygomatic process there, you have the maxilla, and the mandible. And there is the mastoid process there. The mastoid process combines the sternocleidomastoid muscle. Big word, but all it is, is the muscle that connects the mastoid process to the clavicle and the sternum. They call it the sternocleidomastoid muscle. It's this muscle right here. The orbit of the eye is composed of the lower edge of the frontal bone of the skull, right here, the zygoma, the maxilla, and the nasal bone, and it protects the eye from injury. Only about 80% of the eye is actually inside and protected by the eyelids, the eyebrows, the eye orbit. Only an approximate third of the nose is formed by bone. Two-thirds of the distal part of the nose is cartilage. I had a, did a, I'll be brighter, I did a woman who was trying to break up a fight between her two, I don't know if it was pixels or rottweilers, I didn't go long. But you couldn't pull them apart, but she tried to pull them apart, and one of the dogs bit her nose right off. So she looked like Captain America, Red Skull? She looked like Red Skull, just too old. That was it. The nose was completely gone. And I did not go look for it. But you can see how that, you know, the bone is all that was left. The exposed portion of the ear is called the pinna. So if you look here, this is my pinna, is the ear itself. These are the auricles, the rounded, curly ones. This is the lobe, and this is the tragus. And it's designed to filter sounds into the ear canal. This is the TMJ, the temporal mandibular joint. It's the point of articulation of the mandible. This is C1, the first cervical vertebrae, called the atlas. The atlas is fused to the skull, and it connects to the vertebrae below. The second one is C2, which is the axis. It allows you to turn your head as an axis. And then C3 through C7, if you went and felt down the back of your neck, at the point where your neck ends, the most prominent one sticking out, is the spinous process of C7. This is the spinous process. This would be C7. And the spinous process of all of the vertebrae are where muscle connects to, like your latissimus dorsi and your obliques. They all connect to the vertebrae. About one inch posterior to the external opening of the ear is the mastoid process. We talked about that. The mandible forms the jaw and the chin. The neck contains many important structures and is supported by the cervical spine. So we've got this right here. We can see this is the laryngeal prominence. That divot right there, that's where the larynx is, your actual arytenoid cartilage is, your vocal cord. This is the thyroid cartilage. This is the cricothyroid membrane. That's the membrane I can penetrate. If I need to, I can stick a needle in it. It's called puricotinous transtracheal jet ventilation, or a needle crike, if I can't get an airway in it. And then this is the cricoid cartilage, which is the only solid ring of cartilage. This is your sternocleidomastoid muscle. And it shows inside your jugular veins. Your jugular veins, your carotid arteries are kind of on the outside. The jugulars are on the inside, kind of more forward. So these would be your external jugular, your external carotids. Then your jugulars would be a little bit deeper. And then deeper than those are the internal carotids. And again, if you're palpating those, you're pushing way too hard on the napkin, which is probably going to go to sleep by now. So this is with the tissue filleted away. We can look at this. The epiglottis would be right up here. This would be the hyoid bone, which is the only bone that doesn't articulate against any other bone. It's a point of anchor for the esophagus, trachea, and the tongue. This is the thyroid ligament that allows for movement. This is your laryngeal prominence, basically called your Adam's apple. That's where your arytenoid cartilage, your vocal cords are. This is the thyroid cartilage. Below it is the thyroid, the parathyroid, and then the larynx. This is the cricothyroid membrane, and this is the cricoid cartilage. This is the only solid ring of cartilage. All of these going down are all seeds. This is the solid ring, and it's a point of articulation. If I didn't have those structures right there, if I put my head down, my airway would tink, and I wouldn't be able to breathe. It's a point of articulation. That's how we develop like this. It's kind of cool. The trachea, below the larynx, connects to the oropharynx, and the larynx to the passages of the lungs. The trachea is right about here. It begins at the cricoid cartilage and runs down to the carina, which is right about here. About 5 to 10 centimeters long, about 3 to 5 inches. That's where it bifurcates to the right and left main stem bronchi. The sternocleidomastoid muscle, we talked about that. That's the main neck muscle that gets injured like whiplash, or if you're in the shower and you turn your head the wrong way, and you're like, oh, my neck is stiff, I can't turn it. It's the sternocleidomastoid muscle that's irritated. The eye. Globe-shaped, approximately 1 inch in diameter, located in the bony socket of the skull called the orbit. About 80% of it is protected. So, this is the eye. We're going to talk about this. I'm just going to go over it really quickly. I could spend a whole semester on the eye. You don't need to know that. We need to know just what we need for EMS. So, first of all, there are two chambers. You have the anterior chamber and the posterior chamber, so separated by the legs. The anterior chamber is full of a liquid called the aqueous humor. Aqua means water. It's a water-like fluid. It can be replaced if it leaks out. The posterior chamber is called, is filled with a liquid called, or a substance called the vitreous humor. It's almost like a clear jelly, and it gives the eyeball its globular shape. Unlike the aqueous humor, if you lacerate the eye and you see this jelly-like substance coming out of the eye, do not put any pressure on it, lightly bandage it, and that patient's going to end up at mass eye and ear, because you're probably going to lose the eye. So, and I've seen that. I've seen that. One time I saw it, a guy was chipping, a guy was breaking a rock. He had a big rock in his yard, and he was trying to break it with a sledgehammer, and a piece of the rock ricocheted off. He wasn't wearing goggles, got it right in the eye, and it penetrated his eye. You can see the vitreous humor coming out like a jelly. He kind of wanted to spread it on his toes. And then, so, we're going to start from the outside and work our way in. First of all, the outer part of the eye is the cornea. The sclera, the sclera is the outside of the eye. That's the white part of the eye. So the cornea is kind of the clear part of the sclera. It's the very outside of the eye. You can actually do corneal replacements. If you have a damaged cornea and they need to replace it, they can take a cadaverous cornea, remove it, and put it over yours. They can remove your cornea and put a new one on. And if anybody's ever had scratches to their cornea, it feels like you've got something you're out of sand in your eye, and it takes a couple days to heal. The funny thing is, the two fastest parts of the healing, healing parts of the body are the eyes and the mouth. Because you have to see to eat, you have to eat to live. So the fastest parts of the healing part are the eyes. What are the eye floaters? The eye floaters, the eye floaters are actually the remnants of blood vessels. When your eye was developing, you had a lot more blood vessels. And as you were born and as you grew up from a baby, those blood vessels kind of, they degraded. But you still have slates of them in your eye. So those are the floaters you see. Those are remnants of blood vessels that have been absorbed. Or it could also be, sometimes floaters can be like, like some dirt or things that are on your eye itself. Because your eye is almost like a microscope at that point. I'd say in the jelly part, the floaters that he's talking about. Yeah, it's usually in the vitreous tumor. And what you get is when the light comes in, as it passes by those floaters going into the retina, it gives you that shadow. Wow. So there's the cornea, there's the cornea there. Then from the cornea we go into, we have the vitreous tumor, and then we have the lens, the pupil, and the iris. So the iris is the muscle. That's the part that gives us the color of the eye. And that's what dilates and constricts based upon the ocular motor nerve. The hole that gets bigger or smaller is the pupil. So it's the iris that dilates and constricts, producing the pupil size. From there the light goes to the lens, and then it's reflected, the photons of light, and then it hits the back of the eye onto the retina. The retina covers the whole back of the eye, it absorbs those photons of light, and turns it into an electrical signal, and sends it up the optic nerve to your visual cortex. Now, the retina, just like the rest of your eye, needs nourishment. It needs oxygen, vitamins, nutrients, and it has to remove the waste product itself, part of the 50 trillion cells in your body. So it needs a blood supply, and that's what the choroid does. The choroid is on the inside of the sclera, underneath the retina, and it feeds the retina and the eye, and gives it its nourishment. You've got an eye or a vein that comes down this way, the blood circulates through the choroid, and then back up through the vein. So we get bloodshot eyes, right? If you smoke a little bit of the devil's lettuce, you're going to get the bloodshot eyes, or if you're tired, or whatever. It's the dilation of the blood vessels in the choroid. And they dilate, and you get those bloodshot eyes. Thank you, that's just what I was going to get into. If the retina separates from the choroid, we call it retinal detachment. Retinal detachment is usually permanent blindness, because we can't go in and surgically reattach it. So what will happen is a patient can have, and it can happen through trauma, it can happen through a number of different things, but they'll have a black spot, a blind spot. No matter where they look, this eye, at that point, there's always this blind spot. That's a retinal detachment. My father had his retina detached. They weren't able to connect it back together. Did they really? Yeah, they had to inject him with some kind of air, in his eye. And he had to lay it on his face for a couple of weeks, and then they went in, and these are... It really worked. I didn't think they could fix it. Well, that's good to know. I didn't think they could fix it. That's amazing. It must have been quick, though, from the time he had the injury to... He noticed a black vision, like a black spot, that was still there after a couple of days. He can't move his trip anymore, so they did it right away. Oh, here you go. So they can fix it. The clear jelly-like fluid in the back of the eye is called the vitreous humor. Again, we talk about this jelly-like substance. If that's coming out, that's actually the loss of the eye, potentially. In the front of the eye, the fluid is called the aqueous humor, which can leak out in penetrating injuries. They can replace that. Sometimes you can get injuries and damage to the iris, but in the back front, they call it a hyphema. It's blood in the aqueous humor chamber. The body can absorb that. They can fix that, unlike the vitreous humor. Now, the conjunctiva is the membrane that covers the eye. This is all of this around here, inside the lens in here. This is called the conjunctiva, and it actually has your tears, your lacrimal glands up here. Every time you blink, and it cycles the dirt and detritus with the tears into your nasolacrimal ducts. You have your lacrimal bone here, and then you have your lacrimal duct. Those tears drain in there, and actually either swallow, or they go down and run out your nose. That's why when you're crying, it's not a runny nose. It's actually tears. Your tears are coming through your lacrimal duct. If you get inflammation or irritation, that's what we call conjunctivitis. You can have infectious and non-infectious. Non-infectious conjunctivitis can be caused by an irritant. It can be caused by looking at infrared light. Infectious, we call that pink eye. You touch something, the hazard, you touch your eye, and now you've got it, and it goes through like wildfire through preschools, because all kids touch everything and touch their babies. Did you ever, when you wake up in the morning, you get those sleepies in the corner of your eyes? The Sandman comes and gets those sleepies in the corner of your eyes? They call those eye boogies. Do you know why they call them eye boogies? Because your tears and the mucus from your nose are the same chemical makeup. It's the same thing. Mucus is mucus. If you have a mucosal membrane, you have glands that secrete mucus, they're all the same. The sclera is the white fibrous tissue that helps maintain the globular shape. On the front of the eye, the sclera is replaced by the clear transparent membrane called the cornea. That's where the light comes in. And remember, your eye is convex, so everything, all the light when it hits you, it's kind of upside down, and then your eye has to, your visual cortex has to turn it on. The pupil is the opening in the center of the eye. Anuscoria, remember I mentioned this? Unequal pupils. So you have a patient, I look at him, this pupil is bigger than this pupil, but they should equally react. You should have Pearl, but they're not equal because he has anuscoria, but they'll equally react. Now if I look at his eyes, and one is dilated, and it's not reacting, that's something different. But for anuscoria, the pupils will be different in size, but they'll react equally accordingly. The lens behind the iris, the lens lies behind the iris, and that's what focuses the image, and the pupil and the lens act to, either like a telescope for long distance, or a microscope for up close. The retina contains nerve endings that responds to light and sends those signals up the optic nerve. Again, retinal detachment causes blindness, but it can be fixed. Injuries to the face and neck can often lead to partial or complete obstruction of the upper airway. The problem with that is you get bleeding in the face, and that bleeding can, you can get clots that build up in the lungs. Two things can happen. If I'm bleeding, the face and head are very vascular, so you can bleed a lot. 20% of the body's blood flow goes to the head at any given time. So I get a laceration, I'm bleeding. That blood can go in the stomach. The stomach doesn't like frank blood and wants to cause me to do retch and vomit, or the blood can be inhaled, aspirated directly in the lungs. Blood in the lungs, what does it do? It clots. And I've seen big, long clots like that. Blood clots from facial bleeding, direct injuries to the nose, mouth, larynx, and trachea. You can actually have a tracheal disruption, or a tracheal fracture, laryngeal fracture. And what happens is, I actually break the cartilage and I can have a rip in the trachea. So every time I breathe in, air leaks out from the trachea and actually invades into the thoracic cavity, causing what we call a pneumonia stymum, or air in the middle of the sternum, which can be life-threatening. Not only that, but one of the telltale signs of that is they call it subcutaneous emphysema. It's like Rice Krispies under the skin. You palpate, you feel popping under the skin. And that air from the trachea getting into the... If you palpate... If a patient has a neck injury and you palpate subcutaneous emphysema, that patient is ready to take the dirt nap. This is high-priority transport. Call ALS. They're developing a pneumothorax as you speak. Dislodgement, or teeth or dentures into the throat. They get aspirated. They can cause airway obstruction and irritation, lacerations. Sliding that accompanies direct or indirect injuries can cause significant issues. Airway may be affected when the patient turns their head. If I have a laryngeal fracture or a tracheal disruption, I put my head down like this and I can actually lose my airway. If you put my head in line, all of a sudden I go... And I stop breathing again. You could possibly have injury to the brain and spinal cord. So obviously, head and neck go together. If you have a head trauma, consider neck injury. Now look at this guy. He didn't go two rounds with Joe Palooka. Now by looking at that, look at the blood and the way his eye is kind of swollen. What would you consider that to be? Remember we had that last class? What do we think that is? Look at it. He's got that blood, that pink, that blood pooling behind the eye. That's not just a black eye. What do you think that is? That's raccoon eyes. A basilar skull fracture. That's a skull fracture at the base of the skull when blood comes out, which means that he had a wound of infection into his brain because of the fracture of the skull. And look at where he took the impact, right near the temporal region. So I have a basilar skull fracture near the temporal region. What was he at a great risk of? An epidural bleed. So this could have been a life-threatening injury. Obviously, lucky it wasn't. What's that? And he doesn't look very happy. He's been taken a picture of before. Dental injuries. Mandibular fractures are common. One time I did a call for a patient who, driving in a car, wasn't wearing a seatbelt. I don't even know if the car had airbags. It was a long time ago. He must have opened his mouth when he saw the car coming and he caught the steering wheel like this. Ripped his jaw right down. His jaw was hanging. So he put his jaw in place, wrapped it up in a bandage, and then wired his jaw. Most injuries are often the result of vehicle collisions or assaults. Signs of a mandibular fracture include misalignment of teeth. The patient has trouble talking, can't open his mouth, can't move his mouth. The mouth of the jaw is misaligned. Teeth are misaligned. There might be dental fractures. Numbness of the chin. He has no feeling in his chin. Injuries are usually found with blunt force high energy impacts. With a maxillary fracture, you can have three different levels. You can have a LAFORT, L-A-F-O-R-T-E, L-A-F-O-R-T-E, LAFORT fracture. A LAFORT 1 fracture is the maxillary fracture. You might see broken or knocked out teeth, misalignment of teeth. The patient is probably not going to be able to talk. A LAFORT 2 is the maxilla and the bridge of the nose is also fractured. A LAFORT 3 includes the face plate. A complete LAFORT 3 fracture, I should go and pull on your nose and pull out the whole face plate. The whole thing will come out. Pitchers get those. They get a line drive in the face. There's been a couple of pitchers that have complete LAFORT 3 fractures because they get the line drive right in the face. Now remember, a LAFORT 3 fracture, what is the problem with that? Brain involvement, right? There's a potential for bacteria to get in that. Scene safety. Observe for hazards and threats. Make sure that if it's violence, that you're safe. And if there are environmental threats, you take those into account before you make contact with the patient. Eye protection. Face mask is standard. I've gone to patients where I put goggles on or a face mask. Patients are agitated. So they're going to talk with a lot of excitement. They're going to be very animated. You take that face mask off afterwards, it's all splattered with blood. Which means all that blood from the spray as they're talking would have been in my face. In my eyes, in my mouth, in my nose. Goggles, gloves, mask. Absolutely. What's that? Yeah, that's true. You like blood. If you're a vampire. If you get to a patient and you start working the scene becomes unsafe. That's not abandonment, right? If you're working a patient and the scene becomes unsafe and you can't stabilize it, you can leave the scene and it's not abandonment. What I'm trying to do is bring the patient with me if I can. But if I can't, leave the scene. Absolutely, nothing wrong with that. Determine the number of patients. Call for assistance early. Mechanisms of injury and nature of illness. Assess the scene. The scene may give you that. If you have such information and your arrival on scene, your scene assessment, you can probably get the mechanism of injury. You get a good idea of what happened. Common mechanism of injury for patient neck injuries, motor vehicle collisions, sports. Within the 25 mile radius of this building every sport known to man time is played to an equal age. Anybody ever watch Harry Potter? Quidditch. They don't really fly brooms. But Quidditch is kind of a cross They check each other. If you look at these kids from the Holy Cross and you put these kids in the car it would be like bookworms, right? No, these kids play Quidditch. Falls, penetrating trauma, and blunt trauma. Focus on identifying and managing life threats in your primary assessment. Level of consciousness, airway, breathing, circulation. Treat bleeding and airway, breathing, circulation immediately whenever you identify it. For more information visit www.FEMA.gov