Legal Mumbo Jumbo
This document is written a memory refresher for the regular training sessions at the Laingholm Fire Brigade by the Laingholm First Response unit. While the author tries to be accurate, please remember that this document was written as an exercise by someone who is not a doctor.
Here We Go
Injuries to the face and
throat have a number of aspects which make them tricky to handle:
The patient is often in extreme distress or is uncooperative
There is a danger of spinal injury
Blood supply to the area is exceptionally rich, and it comes out
Bleeding and disfigurement may obstruct the airway
It may not be possible to fit an oxygen mask
Overview
As always personal safety
is paramount. There is no point in you getting hit by the same thing that
hit them be it a low beam, washing line, angry spouse or a sniper. This
review covers soft tissue injuries, and most of these are going to be some
kind of nice, juicy, messy trauma. Oxygen through a non-rebreather mask
please, 15 litres per minute and give some to the patient as well.
If a patient with a facial
injury is conscious, it is likely that they and any family members present
are going to be in a fair degree of distress. They may be worried about
the possibility of a permanent facial injury, may be unable to breathe,
are probably concerned at the amount of blood, or are worried about losing
their sight. Reassurance plays a vital role in these patients and guardians.
If the patient is not
fully conscious, they may be intoxicated (full of aggro and beer, had a
bit of a fight, lost badly), have a decreased level of consciousness due
to a head injury or inadequate airway, or suffer a combination of the above.
In extreme cases blood loss will also cause hypovolaemic shock or particularly
with severe lacerations to the neck, take bloodflow away from the brain.
If any bits came off during
the accident, the hospital will want to see them. Detached body parts get
dropped into a saline tube if small enough, or are wrapped in gauze saturated
with saline, popped into a bag, preferably chilled, and are transported
with the patient. If teeth have been knocked out, wash them (don't scrub!)
with saline and drop into a tube as above for the dentist or doctor to
re-attach. If the tooth cannot be found, consider the possibility that
the patient has inhaled or ingested the tooth.
Dentures can stay in the
patient's mouth if they are undamaged and aren't in the way; they may even
prop up broken bits. If they are lose or damaged, remove them and transport
with the patient so the surgeon has something to use to re-align the mouth
against. Don't try them on to see if they fit.
Objects that went into
the patient and that came out again may need to go with the patient so
that the doctor can determine likely internal injuries. If a corrosive
caused the injury, be aware of the hazchem precautions and try to determine
the agent if it can be done safely.
Eyes
If anything is actually
stuck in the eye, don't try to pull it out. If it isn't stuck in but appears
to have adhered to the cornea, leave that alone too. Cover with a cup,
large lid, half a tennis ball or whatever seems clean and about the right
size. The same treatment applies to eyeballs that pop out. Try to arrange
the dressing around the cover rather than over the top of it to avoid pushing
it into the eye. It is no longer considered necessary by St John's to cover
both eyes when one is injured, and the patient is generally happier when
they can still see out of the good eye. If there is no good eye, explain
fully to the patient what is going on and stay with them. They need reassurance
by the bucketload.
Should anything corrosive
or gritty get in the eye, wash it out with saline in one of those cunning
eyebath/washer squirty bottles or lay the patient on their side and irrigate
the eye on their lower side. Eyes are always irrigated from the centre
to the outside, mostly so that you don't go washing crud from one eye into
the other. Irrigate unwanted chemicals in the eye for 20 minutes, longer
for alkalis. This is likely to run you out of saline, so use water. Don't
attempt to use chemical antidotes, diluted vinegar, bicarbonate of soda
etc. Just water or saline and plenty of it. Don't use the high-pressure
delivery.
The hospital will want
to know if the patient tried to remove any objects from the eye themselves,
and what the object or substance was.
If the orbit of the eye
has been chipped (sometimes characterised by the patient being unable to
look up), disfigured, or let the eyeball pop out, it is possible that the
blow was strong enough to cause a cervical spine injury. The older the
person is, the more likely it is to happen. A symptom of an orbital fracture:
One of these eyes is not like the other.
Contact Lenses
Fortunately we only have to remove contact lenses in the event of a chemical getting into the eye. Basically, soft ones get gently pinched out, hard ones get squeezed out, applying slightly more pressure to the lower eyelid. Do not pressurise perforated eyeballs. Patients may wear contact lenses in one eye only, so check both.
Face
As with any cut to the head, a patient with a cut face is likely to bleed like a stuck pig. Treat as per any other soft tissue injury but be careful with facial nerves in cheek and jaw injuries. Flaps of skin, eyelids, lost ears etc. can be re-attached, so save them in cold, moist conditions as per usual. Try not to get the patient's parts mixed up with anybody else's. A sufficiently enthusiastic injury to the eyelid may well result in damage to the eye. Worth checking; the following images show trauma caused by a BB pellet penetrating the eyelid and the final location of the BB:
Cheek injuries can be
held under pressure by putting one finger or thumb inside a cooperative,
alert patient's mouth. However one has to consider the danger to the digit.
Assume that any solid
thump landed on the face or jaw may have caused cervical spine injuries,
and/or rattled the brain around enough to cause some damage. If fluid is
coming out of the ear, check it to make sure it is not concealing cerebrospinal
fluid from a fractured skull. The face is part of the container for the
brain, and severe facial injuries can cause some brain injury.
Nose injuries are treated
as per other soft tissue injuries. Broken noses get a cool pack. Nosebleeds
need to be left to bleed if the patient has a head injury in case it is
the result of a skull fracture. Blocking up the outgoing blood may raise
the pressure inside the skull. For a plain old nosebleed, get the patient
to sit leaning slightly forward, pinch the fleshy part of the nostrils
together. If there's any foreign object up that thar nose, leave it for
the hospital staff to fish out -the same applies to ears.
If the injury has damaged the oral cavity, avoid using an O.P. airway.
Neck
Injuries to the neck can't
help but come close to major blood vessels and the airways. Blood flow
is generally staunched by firm pressure with a large dressing and gloved
hand. Use a dressing that is not going to disappear into the wound, and
make sure there are no surprise objects in the wound before applying pressure
- but don't probe. Try not to trap air as getting air into the brain's
blood supply system is seriously bad for the heath. Don't apply
tourniquets around the neck!
Don't apply pressure
to both sides of the neck simultaneously. If you do need to apply a dressing
to a wound to the side of the neck, bandage in a figure of 8 path under
the opposite armpit. If injuries are more than superficial, the patient
should have their head held in neutral alignment - this will have to be
done by hand.
Signs and symptoms of
an injured neck include:
Difficulty speaking
Loss of voice
Mysterious airway obstructions
Crepitation as air enters the body from leaks in the trachea
Displacement of the trachea (also indicates chest injuries)
And that's all I have
to say about facial, eye and throat injuries. You've been a wonderful audience
and I've been talking for too long. Goodnight.
Vik Olliver, 29 Nov 2000 vik@asi.org