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Caution: Consider need for C-Spine Control Posterior Tongue Displacement

1. Unconscious patient: Jaw thrust or chin lift. Pull tongue forward or insert airway adjunct if needed.

2. Conscious patient: Most common cause is bilateral mandible fracture. Have patient bend forward as needed to maintain his/her airway

Oropharyngeal Bleeding:

1. Rotate supine patient to the side. Allow for drainage.

2. Suction & apply direct pressure if possible.

Edema:

1. Early intubation if possible

2. If unable to intubate, cricothyroidotomy may be needed Blood Loss from Facial Trauma:

1. Pressure dressing can be applied to most areas of the face.

2. Severe Tongue Laceration: If pressure unsuccessful, a few sutures may be needed.

3. Gingiva, Floor of Mouth, Buccal Mucosa: Pressure dressing with roll of sterile gauze. Have patient bite on roll or hold in place with pressure.

Epistaxis (Nasal Bleeding):

1. Direct pressure: Pinch anterior portion of nose between fingers for a minimum of 5 minutes.

2. Oxymetazoline nasal spray: Give 2 squirts in each nostril 3. Packing: Anterior or Posterior.

4. Anterior Pack: Layer strips of petrolatum gauze in one or both nostrils.

5. Posterior Pack: Used if bleeding persists in the nasopharynx after the anterior packing.

6. Antibiotics all patients who have had nasal packing should be given (Moxifloxacin, 400 mg PO q 24 h, or Ertapenem 1 gram IV/IM q 24 h.)

CAUTION: DO NOT attempt to pack a nose if a cerebral spinal fluid (CSF) leak is suspected.

NOTE: Observe patient closely. If the posterior pack becomes loose it can easily obstruct the airway. Remove packing. Insert Foley catheter through the nose until it is visualized in the pharynx. Inflate balloon with approx. 15cc of fluid. Put traction on the catheter, setting the balloon into the back of the nose. Once in place, pack around the catheter with petrolatum gauze and maintain traction. If there are no contraindications, patients who require a posterior pack should receive sedation. Observe closely for decreased respirations if a posterior pack is in place in a sedated patient.

Disposition:

 Evacuation is not required if bleeding has been controlled and resolves with treatment

 Priority evacuation for severe epistaxis not responding to therapy or if Foley catheter is used Ocular Trauma:

Guidelines and Considerations:

 Obtain history of injury, pre-existing conditions, i.e. contact lens use.

 If chemically induced, note type of chemical, treatment, visual disturbance, pain, any other associated injuries.

 Obtain gross visual acuity and record. Visual acuity can be as simple as light perception, counting fingers at three feet, read this book at 2 feet, etc.

NOTE: Always obtain a visual acuity with ocular injuries! (Before and after treatment, if possible) CAUTION: In cases of chemical splash injury to the eye, begin irrigation immediately.

Physical Examination:

Blepharospasm (blinking &/or forceful holding eyes shut) secondary to eye pain/discomfort often hinders an adequate ocular exam. This may often be overcome by a one-time only instillation of 1-2 drops of a topical ophthalmic anesthetic eye drop solution (e.g., Tetracaine or Proparacaine). In addition to providing immediate pain relief and facilitating adequate patient evaluation, this also has some diagnostic value. If acute eye pain fails to improve after use of a topical ophthalmic anesthetic agent, this may be an indication of serious intraocular pathology and requires prompt evacuation.

NOTE: Never give topical anesthetic eye drops to patients to use on their own. Repeated use can cause corneal toxicity and predispose to ocular infection!

Eyelids: Assess for edema, bruising, burns, movement and strength, ptosis (ie. drooping eyelids), foreign bodies penetrating the globe.

Orbital rim: Gently palpate for depressed fractures or loss of sensation to the skin above and below the globe.

Globe: Retract lids without applying pressure to globe. Examine/assess for: Forward or retro displacement of the globe; normal movement and double vision at the extremes of gaze;

integrity of the globe; foreign body or obvious damage.

Conjunctiva: Assess for signs of infection, evidence of subconjunctival air, hemorrhage, or foreign bodies.

Cornea: Assess for tears, abrasions and clarity.

Pupils: Assess for red light reflex, reactivity to light, and shape.

Anterior chamber: Assess for blood (and pus if delayed presentation of an ocular injury), clarity;

dislocation of lens. (May require use of a magnification device, such as ophthalmoscope or

“Bluminator” lens, to detect/appreciate) Lens: Examine for clarity and position.

Specific Injuries and Treatment:

Any acute and persistent decrease in Visual Acuity (VA) requires prompt on-line medical consultation.

If on-line communication is not available evacuate the patient urgently.

Lid: Examine for foreign bodies. Evert the lid and examine the globe for laceration, penetrating injury, and impaled object.

Treatment: Apply dressing and transport. DO NOT suture lid lacerations.

Corneal Abrasion: Examine for pain, foreign body sensation, and photophobia.

Treatment: Instill ophthalmic antibiotic ointment or drops; provide adequate pain meds Disposition: Priority evacuation

Foreign Body: Examine for pain, foreign body sensation.

Treatment: Irrigate eye and treat as for corneal abrasion. If foreign body is still present instill antibiotic ointment. Patch both eyes to prevent eye movement.

Disposition: Priority evacuation

CAUTION: If you suspect a foreign body has penetrated the anterior or posterior chamber do not patch and do not use ointment. Shield eye and give Moxifloxacin 400 mg PO every 24 hours.

Blood in Anterior Chamber (Hyphema): A sign of possibly severe eye injury.

Treatment: Keep patient as still as possible, maintain sitting position Disposition: Priority evacuation

Iritis: May present as constricted, dilated or irregular pupil; hyphema or severe photophobia.

Treatment: Rest

Disposition: Priority evacuation

Lens: The only lens injury you may be able to assess in the field is an anterior lens dislocation.

Treatment: Rest and transport.

Disposition: Priority evacuation

Vitreous: Blood in the posterior chamber can interfere with light transfer through the vitreous fluid and produce a black rather than a red fundoscopic reflex.

Treatment: Rest

Disposition: Immediate transport/Urgent Evacuation (combat)

Globe: Possible ruptured globe; Possible marked visual impairment. Vitreous may be seen extruding from the globe. Globe may be soft and anterior chamber flat or shallow.

Bloody chemosis = penetrating ocular globe injury until proven otherwise.

Treatment: Eye shield (no pressure applied to globe) and moist dressing. Moxifloxacin 400 mg po Q 24 hrs.

Disposition: Immediate transport/Urgent Evacuation (combat)

CAUTION: Palpation of globe may cause increased loss of vitreous fluid.

Chemical Injuries: History and physical examination.

Treatment: Copious irrigation for at least 30 minutes prior to &/or during transport. Use water, normal saline or lactated ringers.

Disposition: Immediate transport/Urgent Evacuation (combat) NOTE: Any water will do in a pinch.

CAUTION: If the victim has had any chemicals splashed into the eye, irrigation must begin AT ONCE. This is the only time you do not take the time to evaluate the visual acuity (VA) prior to starting treatment. If the chemical was an alkali compound (e.g., lye or ammonia) continue irrigation for a minimum of 60 minutes or until directed to stop by medical control.

Obtain VA‟s immediately following adequate and copious irrigation.

Traumatic Enucleation: Globe displaced from orbit.

Treatment: Protect globe with moist sterile gauze, shield globe and immediate transport.

Disposition: Immediate transport/Urgent Evacuation (combat)

Snellen Visual Acuity Chart

REDUCED SNELLEN CHART

E

N Z

Y L S

U F V P ---60 N S T R F ---40

R O L C T B ---30

M E V P T R U ---20

Designation at side of line represents Visual Acuity in Snellen notation for 16’’ viewing