UNITED STATES MARINE CORPS
Field Medical Training Battalion
Camp Lejeune
FMST
1406
Manage Head, Neck, and Face Injuries
TERMINAL LEARNING OBJECTIVES
1.
Given a casualty with either head, neck or face
injuries in a combat environment and standard field medical equipment and
supplies, manage head, neck and facial injuries, to prevent further injury or
death. (FMST-HSS-1406)
ENABLING LEARNING OBJECTIVES
1.
Without the aid of references, given a description
or title, identify the anatomy of the head, per the student handout.
(FMST-HSS-1406a)
2.
Without the aid of references, given a description
or title, identify the anatomy of the neck, per the student handout.
(FMST-HSS-1406b)
3.
Without the aid of references, given a description
or title, identify the anatomy of the face, per the student handout.
(FMST-HSS-1406c)
4.
Without the aid of references, given a description,
select the appropriate treatment for a head injury, per student handout.
(FMST-HSS-1406d)
5.
Without the aid of references, given a description
or list, select the appropriate treatment for a neck injury, per student
handout. (FMST-HSS-1406e)
6.
Without the aid of references, given a description
or list, select the appropriate treatment for a facial injury, per student
handout. (FMST-HSS-1406f)
7.
Without the aid of references, given a simulated
casualty with head, face, and neck injuries and standard field medical equipment
and supplies, manage casualties, per the student handout. (FMST-HSS-1406g)
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Substitute Figure 1. Anatomy of the Head
*
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1.
ANATOMY OF THE HEAD
Head
(see figure 1)
Cranial Vault
- the part of the skull that contains the brain and is divided into six
sections:
-
Occipital - the posterior lobe of each cerebral hemisphere that bears the visual
cortex and has the form of a 3-sided pyramid
-
Temporal - a large lobe of each cerebral hemisphere that is situated in front of
the occipital lobe and contains a sensory area associated with the organ of
hearing
- Parietal - forming the upper posterior wall of the head
- Frontal - the anterior division of each cerebral hemisphere
- Sphenoid - a winged compound bone of the base of the cranium
-
Ethmoid - a light spongy cubical bone
forming much of the walls of the nasal cavity and part of those of the orbits
Brain
- divided into three major areas:
Cerebrum:
The largest of the three subdivisions of the brain, superiorly situated and
sometimes called the “gray matter”. It controls willful movement, sensory
information such as hearing, speech, visual perception, emotions and
personality.
Cerebellum:
Situated posterior to the brain stem and is sometimes called the “little brain”
or “white matter.” It coordinates the various activities of the brain,
particularly movement, coordination and balance.
Brain Stem
- broken down into four parts which connect the spinal cord to the brain and
cranial nerves:
Medulla - the most inferior part of the stem which
contains the center that regulates respiratory rate, blood pressure, heart rate,
breathing, swallowing and vomiting.
Pons
- sleep center and respiratory center.
Midbrain - regulates muscle tone.
Reticular Activating System - scattered throughout the
brain stem and is important in arousing and maintaining consciousness.
2.
TYPES OF HEAD INJURIES
Soft Tissue Injuries
Definition
- injury to the overlying skin of the scalp, which may be in combination with
injury to the skull, brain and/or face.
Causes
-
Penetrating trauma (rifle, impaled objects, missile wounds)
- Blunt trauma (MVA, blast)
Skull Injuries
Open
Skull Injuries
Definition
- injury where cerebral substance is visable through a scalp laceration. Open
head injuries usually combine lacerations of the scalp, fragmentation of the
skull from fractures, and lacerations of the membranes that cover the brain.
The brain may be relatively untouched, or it may be extensively bruised or
lacerated.
Causes
-
Penetrating trauma
- Blunt trauma
Closed Skull Injuries
Definition
- in closed head injuries there may or may not be lacerations of the scalp, but
the skull is intact, and there is no opening to the brain. Injury to the brain
itself may be far more extensive in a closed head injury because more of the
injuring force is transmitted deeper into the brain due to pressure build-up
(see figure 3).
Causes
Coup-Contrecoup
- also known as a deceleration injury. It occurs when the brain strikes the
frontal lobe of the skull, then is thrown back against the occipital lobe of the
skull (or in the reverse order), causing the brain to bounce off both sides of
the cranial vault, resulting in soft tissue damage.
Blunt Trauma - rising intracranial pressure (ICP)
produces complications because the brain is enclosed and pressure cannot be
relieved.
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Substitute Figure 3. Closed Head Injury*
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Brain Injuries
Definition - results from contusion, hemorrhage and/or
edema. Damage to the brain and associated intracranial hemorrhage may occur
with or without scalp lacertions
or skull
fractures. If the cranial vault is intact, the resultant swelling or bleeding
produces more brain injury by increasing the intracranial pressure.
Causes
- Blunt trauma
- Penetrating trauma
- Coup-Contrecoup injuries
3.
Signs and Symptoms of Head Injuries
Soft tissue injuries
-
Profuse bleeding no matter how minor the injury
-
Lacerations
-
Avulsions
- Pain
-
Anxiety
- Edema
-
Ecchymosis
- Signs / symptoms of hypovolemic
shock
Open Skull injuries
-
Profuse bleeding no matter how minor the injury
-
Crepitus
-
Edema
-
Depressions
-
Deformities
- Visualize skull or bony fragments
Substitute Figure 4.
Unequal
Pupils*
Substitute Figure 5.
Raccoon Eyes from a basilar
skull fracture*
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Closed Skull Injuries
- Crepitus
around injury site
- Headache
-
Neurological symptoms:
- Altered LOC
-
Restlessness
-
Unequal pupils (see figure 4)
- Bruising, such as:
Raccoon
Eyes - discoloration of the soft tissue under the eyes indicates basilar
skull fracture (see figure 5).
Battle’s sign
- discoloration of the soft tissue behind the ear indicates temporal bone
fracture. This is a late sign and may not be readily seen.
- Drainage - drainage of cerebral spinal fluid from the ears,
nose, or eyes. Blood or fluid (CSF) in the ears or nose may indicate a skull
fracture.
- Bradycardia
- Increased systolic blood pressure
- Nausea/vomiting
- Decreased Respirations/Cheyne Stokes breathing pattern
- Deformity
of the skull
Brain
Injuries - in addition to the above listed signs and
symptoms for closed skull injuries, the below listed signs and symptoms may
indicated a brain injury as well:
-
Unusual behavior patterns. You must be careful not to misinterpret these
symptoms for a psychiatric casualty. (This is the number one indicator of an
injury.)
- Altered
level of consciousness
- Paralysis
-
Convulsions/seizures
- Hyperthermia
Determining
Responsiveness (AVPU) - AVPU is an acronym used by health care providers to
standardize the way of describing a patient’s mental status. The level of
responsiveness aids in the determination of the casualty’s baseline. The
responsiveness of the casualty can begin to be assessed from a distance as you
approach a casualty by saying, “Hey, if you can hear me, crawl towards my
voice!”
A
(Alert) - is the casualty oriented to person, place, and day? If so, obtain
chief complaint.
V
(Verbal stimuli) - casualty’s response to verbal stimulus (appropriate or
inappropriate?).
P
(Painful stimuli) - casualty’s response to painful stimulus (localizes or
withdraws to pain).
U
(Unresponsive) - casualty is totally unresponsive.
4.
TREATMENT OF HEAD INJURIES
-
Provide and maintain patent airway
-
Apply c-spine precautions
- Hemorrhage control. Cover open wounds securely enough to aid
in the clotting process without pressing skull fragments or impaled objects
inward by using donut o-ring.
- Fluid resuscitation PRN (as needed) (Do not want to raise
intracranial pressure)
- Do not
remove foreign bodies or impaled objects
- Check for drainage of CSF from the wound, nose, or ears. Do
not pack or suction nose and/or ears if CSF leakage is suspected. Do not let
patient clear their nose by blowing. If the casualty has draining from their
nose, check to see if it is CSF by:
- Use the
Halo, or Target Test to check for CSF. Dip a 4 x 4 in the drainage then lay it
flat and wait a few minutes. If there is CSF in the blood, the blood will collect
in the center, while the CSF remains to the outside creating a halo around the
blood.
 -
Give nothing by mouth (NPO)
-
CASEVAC
in the high Fowlers position
NOTE:
There is a high mortality rate associated with head trauma. All head trauma
patients are assumed to have a cervical spine injury until proven otherwise.
5.
ANATOMY OF THE NECK
Structures
Esophagus - passage from the mouth to the stomach
Trachea (windpipe) - air passage from the larynx to
the lungs made of connective tissue and reinforced with 15-20 C-shaped
cartilaginous rings
Thyroid gland - stimulates the metabolism of all cells
Larynx
(voice box) - the first part of the trachea which
contains the vocal cords
Pharynx - area that extends from the soft palate to
the esophagus/trachea
Epiglottis
- leaf shaped structure that acts like a gate, directing air to the trachea and
solids and liquids into the esophagus
Vasculature
Arteries - left/right common carotid
(carry blood to brain)
Veins
- left/right internal and external jugular (carry blood away from brain to
heart)
Cervical Spine
Vertebrae - seven cervical vertabrae
Spinal Cord
- protected by the cervical vertebrae
6. TYPES OF
NECK INJURIES
Trauma of any kind to the neck is
signifigant because of the risk of associated injuries to the respiratory tract,
the alimentary tract (especially the esophagus), the major vascular structures,
major nerves, and the cervical spine.
Structures
Definition - injury to associated anatomy of the neck
most commonly the trachea and esophagus.
Causes
-
Blunt trauma
- Penetrating trauma
Vasculature
Definition - injury to the carotid arteries and/or the
jugular veins. These are the most commonly injured structures of the neck.
Causes
-
Blunt trauma
- Penetrating trauma
Cervical Spine
Definition - fractures of the cervical vertebrae which
are very susceptible to injury because of the relation and position of the
skull. These fractures may result in irreversible spinal cord injury.
Causes
 -
Compression injury (see figure 8).
-
Flexion, hyperextension and hyperrotation
-
Lateral bending
7.
SIGNS AND SYMPTOMS OF NECK INJURIES
Structure
-
Subcutaneous emphysema
-
Hematemesis
-
Hemoptysis
-
Dysphagia (difficulty swallowing)
-
Dyspnea
-
Hoarseness
- Deformity
Vasculature
-
Hemorrhage
 -
Hemoptysis
- Hematemesis
Cervical Spine
-
Deformity
- Head
fixed in an abnormal position
-
Muscle spasms
-
Parasthesia in the arms
- Pain
-
Paralysis
- Neural deficits
8.
TREATMENT FOR NECK INJURIES
- Consider C-spine
-
Control hemorrhage with occlusive dressing. Apply pressure only to the affected
vessels
-
Consider cricothyroidotomy if airway is compromised
-
Administer fluids (see Combat Fluid Resucitation lesson)
- NO
PAIN MEDICATIONS! NO PAIN MEDICATIONS! NO PAIN MEDICATIONS!
-
CASEVAC
9.
ANATOMY OF THE FACE
(see figure 9)
The facial bones form the stucture
of the face in the anterior skull but do not contribute to the cranial vault.
The
major facial bones are:
- Nasal
-
Zygomatic - a bone of the face below the eye that in mammals forms part of the
zygomatic arch and part of the orbit
-
Right/ left Maxilla - either of the two bones that lie on each side of the upper
jaw
-
Mandible (jawbone) - the lower jaw.
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Substitute Figure 9. Major Facial Bones*
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10.
TYPES OF FACIAL INJURIES
Generally serious because of the
danger of hemorrhage due to the vast blood supply of the area and obstruction of
the respiratory passages.
Soft Tissue Injuries
Definition - damage to the soft tissues of the face
without bone injuries
Causes
-
Blunt trauma
- Penetrating trauma
Bone Injuries (Maxillofacial and Mandibular)
Definition - fracture of the major bones of the face
(maxillofacial and mandibular). These fractures require great force and may be
open or closed.
Causes
-
Blunt trauma
- Penetrating trauma
Eye
Injuries
Definition - injuries to the eyes that may be
associated with other forms of head injury.
Causes
-
Blunt trauma
-
Penetrating trauma
-
Burns
- Foreign objects-debris
Fractured Nose - prior to control of bleeding, you
must determine that there is no cerebral spinal fluid escaping. If fluid is
escaping, treat as a skull fracture.
11.
SIGNS AND SYMPTOMS OF FACIAL INJURIES
Soft Tissue Injuries
-
Massive hemmorhage even with minor wounds
- Edema
-
Laceration
-
Ecchymosis
- Avulsion
Bone Injuries
-
Lacerated gums may indicate an underlying fracture
-
Casualty cannot open mouth without pain
-
Misaligned teeth
-
Difficulty swallowing
- Pain
at fracture site
- Edema
-
Facial asymmetry
-
Epistaxis (Nose bleed)
-
Ecchymosis
-
Lacerations
-
Visual disturbances
-
Limited ocular movements
- Crepitus
Eye
Injuries
- Loss of
vision
- Pain
- Anxiety
-
Hemorrhage
-
Subconjunctival hemmorrhage
- Orbital
bony deformity
- Intraorbital deformity
Nose Injuries
- Blood
or CSF from nose
-
Bruising
12.
TREATMENT OF FACIAL INJURIES
Soft Tissue injuries
-
Consider C-spine
-
Assess and secure airway
-
Hemorrhage control
- Fluid resuscitation protocol for
associated shock
Bone Injuries
- Maintain
open airway. Consider use of Nasopharengeal Airway (NPA) (see figure 10)
-
Control hemorrhage
- NO PAIN MEDICATIONS! NO PAIN MEDICATIONS!
- Cold pack
- Modified Barton bandage for mandibular fracture
- CASEVAC
Eye
Injuries
- In combat, only patch the affected eye. Member can function
effectively with one eye. Member becomes a litter patient if both eyes are
covered.
- If
the injury to the eye is clearly a minor one,
the best advice is to REFRAIN FROM INTERFERENCE. A minor eye injury improperly
cared for can easily become a major eye injury.
Treatment
for Chemical Burns of the Eye
- Hold the
face under running water with eyes open
- Flush
eyes 5-10 minutes for acid burns
- Flush
eyes 20 minutes for alkali
- CASEVAC
Treatment for Thermal Burns of the Eye
- Cover eye with loose moist dressing
Treatment for Light Injuries
- Cover eye with loose dressing
Treatment
for Impaled Object
- Make thick dressing and cut hole in center the size of eye
opening
- Pass
dressing over impaled object
- Position crushed cup over dressing and bandage in place
- Elevate head to decrease intraocular pressure
Treatment for Lacerations Involving the Eye
- If only eyelid is lacerated, direct pressure or a pressure
dressing will stop bleeding.
- If the eyeball itself is lacerated, do not use pressure, but
cover with a loose dressing.
Treatment for Protruding Globe
- DO NOT
attempt to place eye back in socket
-
Apply bulky dressing around eye, moist gauze over the globe and cover with a cup
secured in place
Treatment of Nose Injuries
-
Hemorrhage Control
- Pinching
nostrils. (Do not tilt patient head back due to postnasal drainage)
- Apply ice
to bridge of nose
- Splint by
padding
- Monitor
and CASEVAC
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CASUALTY
ASSESSMENT AND THE HEAD, NECK, AND FACE
 Care
Under Fire Phase: In
the absense of life-threatening hemorrhage from the Head, Neck, or Face, the
material in this section is unlikely to be addressed in Care Under Fire.
Tactical Field Care Phase:
During Tactical Field
Care, you will be required to inspect the head, neck, and face for any signs
of injury. This includes looking not only for bone deformity and soft
tissue injuries, signs of closed head trauma, and also consider the
possibility of Traumatic Brain Injury (TBI). You must visually inspect the
eyes, ears, nose, and throat. Assess the airway and intervene if
necessary. Complete a head to toe assessment using DCAP-BTLS noting and
treating additional injuries. Determine if vascular access is required (see
Combat Fluid Resuscitation lesson) and give fluids if necessary. If a head
injury is suspected, it is NOT recommended to give casualty fluids by
mouth. Consider pain medications and give antibiotics if warranted.
Reassess all care provided. Document care given, prevent hypothermia, and
CASEVAC. |
REFERENCE
Pre-Hospital Trauma Life
Support, Military Edition, 6th Ed, Chapter 8
REV: July 2008
Head, Neck, and Face Review
1. Identify the function of the
Cerebellum.
2. List the six key points for
treatment of a neck wound.
3. List the appropriate
treatment for a single eye injury in a combat situation.
4. Identify the appropriate
treatment for chemical burns to the eye.
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