Detailed Lesson Plan
Chapter 33
Eye, Face, and Neck Trauma
90–100 minutes
Chapter 33 objectives can be found in an accompanying folder.These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. /
Minutes / Content Outline / Master Teaching Notes /
5 / I. Introduction
A. During this lesson, students will learn special considerations of assessment and emergency care for a patient suffering eye, face, and neck injuries.
B. Case Study
1. Present Dispatch and Upon Arrival information from the chapter.
2. Discuss with students how they would proceed. / Case Study Discussion
· Are there any scene hazards that you need to address before approaching the patient?
· Aside from the patient’s complaint of eye pain and blindness, are there other injuries you should anticipate?
5 / II. Anatomy of the Eye, Face, and Neck—The Eye
A. Globe (eyeball)—Sphere approximately one inch in diameter
B. Sclera—Tough outer coat covering the globe (visible part is “white” of eye)
C. Cornea—Clear front portion of the eye
1. Window through which light enters the eye
2. Extremely sensitive and susceptible to injury
3. Superficial scratch can cause extreme pain, redness, and flow of tears.
D. Pupil—Dark center of eye; expands and contracts to control amount of light allowed through lens
E. Iris—Colored portion of the eye
F. Lens—Just behind pupil; focuses light on retina
G. Retina—Back of the eye
H. Conjunctiva—Lining of inner surface of eyelids and exposed portion of sclera
I. Anterior chamber—Anterior to iris; filled with watery fluid called aqueous humor
J. Aqueous humor—Watery fluid that fills anterior chamber
K. Vitreous body—Behind the lens; filled with clear jelly called vitreous humor
L. Vitreous humor—Clear jelly that fills the vitreous body
M. Orbits (eye sockets)—Bony structures of skull that surround the eyes / Teaching Tip
Use anatomical models to review the structures of the eye, face, and neck.
Discussion Questions
· What is the pupil of the eye?
· What is the orbit of the eye?
Class Activity
Have each student, without opening the book, draw and label the anatomy of the eye. Then have groups of students compare and compile their drawings and come up with a revised, labeled drawing to turn in for review.
5 / III. Anatomy of the Eye, Face, and Neck—The Face
A. The face is comprised of 14 of the skull bones.
1. 13 of the facial bones are immovable.
a. Orbits of the eyes (eye sockets)
b. Nasal bones
c. Zygomatic bones (cheekbones)
d. Maxillae (fused upper jaw bones)
2. The mandible (lower jaw) moves on hinged joints.
B. The face is extremely vascular (contains many blood vessels), so facial injuries may bleed profusely.
C. Facial bones provide minimum protection for the airway.
D. Facial bones allow points of attachment for muscles that control facial expression and manipulation of food.
E. Compromise of facial structure can also cause closed or open brain injury.
F. Mechanism that causes injury to the face is likely to have injured the spine as well. / Discussion Question
What bones make up the face?
5 / IV. Anatomy of the Eye, Face, and Neck—The Neck
A. Body systems within the neck
1. Cardiovascular—Carotid arteries and jugular veins
2. Musculoskeletal
3. Central nervous
4. Respiratory
5. Digestive
6. Endocrine
B. Major structures of the airway within the neck
1. Trachea
2. Larynx
C. Major concerns with injuries to the neck
1. Damages to structure of airway are serious life threats.
2. Any neck injury should automatically be assumed to have caused spine injury. / Discussion Question
What structures are contained in the neck?
Critical Thinking Discussion
What would be the consequences of injury to the thyroid gland in the neck?
15 / V. Eye, Face, and Neck Injuries—Assessment-Based Approach: Eye, Face, and Neck Injuries
A. Scene size-up
1. Think about forces behind injury as soon as you get the dispatcher’s call.
a. Motor vehicle crash (over 50 percent of all facial trauma cases)
b. Assault
c. Sports-related injury
2. Be prepared to gather information from bystanders as patient is likely to be in great pain and emotionally distraught.
3. Protect your own safety; call for police backup if assault is involved.
B. Primary assessment
1. Establish manual in-line stabilization of the head and neck on first contact.
2. Control major bleeding with direct pressure.
3. Open the airway using the jaw-thrust maneuver and suction vomitus and other substances as needed.
4. Consider advanced life support backup, if available.
5. If breathing is adequate, provide oxygen at 15 lpm by nonrebreather mask.
6. If breathing is inadequate, provide positive pressure ventilation with supplemental oxygen at 10–12 ventilations per minute.
7. Recognize which injuries are high priority for immediate patient transport.
a. Chemical burns to the eye
b. Impaled object in the eye
c. Respiratory distress
d. Severe injuries to the face or neck
e. Major bleeding
f. Airway compromise
C. Secondary assessment
1. Inspect and gently palpate for signs of injury to eye sockets, cheekbones, nose, and jaw.
2. Use a small penlight to examine eyes.
3. Record vital signs.
4. If patient is bleeding severely, be prepared to treat shock.
5. Obtain a history.
6. Ask questions about the events leading up to the injury.
D. Reassessment
1. Conduct a reassessment and check interventions.
a. For unstable patient, reassess every five minutes.
b. For stable patient, reassess every 15 minutes.
2. Monitor for deterioration of mental status, airway, or breathing. / Discussion Question
What are some causes of airway compromise in the patient with injuries to the eye, face, or neck?
25 / VI. Specific Injuries Involving the Eye, Face, and Neck—Injuries to the Eye
A. Assessment and care guidelines
1. Use a small penlight to evaluate the following.
a. Orbits for bruising, swelling, laceration, tenderness
b. Lids for bruising, swelling, laceration
c. Conjunctivae for redness, pulsing, foreign bodies
d. Globes for redness, abnormal color, laceration
e. Pupils for size, shape, equality, reactivity to light
2. Test whether the patient’s eyes can follow your finger normally as you move it up, down, left, and right.
3. Remember the following basic rules.
a. Avoid unnecessary manipulation of an eye that is swollen shut.
b. Do not try to force the eyelid open unless you have to wash out chemicals.
c. Consult local protocol before irrigating.
d. Do not put salve or medicine in an injured eye.
e. Do not remove blood or blood clots from the eye.
f. Have the patient lie down and keep quiet.
g. Limit use of the uninjured eye.
h. Give the patient nothing by mouth because hospital may use general anesthesia.
i. Transport all patients with eye injuries for evaluation by a physician.
j. Never apply direct pressure to an injured eye.
4. For foreign object in the eye
a. Determine if patient or others made any attempt to remove object.
b. Attempt to remove only if object is in the conjunctiva.
c. Flush the eye with clean water.
d. Pull down on lid while patient looks up, or pull up on lid while patient looks down; then remove object with sterile gauze or swab.
e. Draw upper lid over lower lid, then back, allowing lower lashes to dislodge object.
f. Grasp upper lashes to turn lid upward; remove object with sterile gauze or swab.
g. Pull lower lid down and remove object with sterile gauze or swab.
h. Do not attempt to remove object lodged in globe; bandage both eyes and transport patient as soon as possible.
5. For injury to the orbits
a. Establish and maintain spine stabilization if orbital fracture is suspected.
b. Look for signs and symptoms of orbital fracture.
i. Diplopia (double vision)
ii. Marked decrease in vision
iii. Loss of sensation above the eyebrow, over the cheek, or in the upper lip
iv. Nasal discharge
v. Tenderness to palpitation
vi. Bony “step-off” (defect in smooth countour of bone)
vii. Paralysis of upward gaze in the involved eye
c. If the eyeball is uninjured, place cold packs over the injured eye and transport patient in a sitting position.
d. If the eyeball is injured, do not use cold packs, and transport the patient in a supine position.
6. For lid injury (bruising, burn, laceration)
a. Inspect the area around the lid for evidence of injury.
b. Control bleeding with a light pressure from a dressing.
c. Use no pressure if the eyeball itself is injured.
d. Cover the lid with sterile gauze soaked in saline to keep wound from drying.
e. Preserve any avulsed skin and transport for possible grafting.
f. If eyeball is uninjured, cover injured lid with cold compress.
g. Cover the uninjured eye with a bandage to decrease movement.
h. Transport.
7. For injury to the globe
a. Use caution; these injuries are best treated at the hospital.
b. Apply patches lightly to both eyes.
c. Do not apply patch if you suspect a ruptured eyeball.
d. Avoid the use of cold packs.
e. If you use an eye shield, be sure it puts no pressure on the injury.
f. Keep the patient supine for transport.
8. For chemical burn to the eye
a. Begin treatment immediately.
b. Irrigate with clean water or sterile saline.
c. Hold the eyelids open so all chemicals can be washed out.
d. Continue to irrigate for at least 20 minutes (if alkalai is involved, for at least an hour) until arrival at the hospital.
e. Use running water or continually pour from the inside corner.
f. Take care not to contaminate the uninjured eye.
g. You may have to force the lids open since the pain may be too great for the patient to open his eyes.
h. Use no irrigants other than clean water or sterile saline.
i. Never irrigate the eye with any chemical antidote (such as alcohol or sodium bicarbonate).
j. Remove or flush out contact lenses; remove solid particles from eye surface with a swab.
k. Place the patient on his side on a stretcher, with a basin or towels under his head, and continue irrigation throughout transport.
l. Following irrigation, wash your hands thoroughly and clean under your nails with a nail brush.
9. For impaled object in the eye or extruded eyeball
a. Place the patient supine and immobilize head and spine.
b. Encircle the eye and impaled object or extruded eyeball with a gauze dressing.
c. Do not apply pressure; you can cut a hole in the dressing to accommodate the impaled object.
d. Place a metal shield, crushed paper cup, or cone over the impaled object.
e. Hold the cup and dressing in place with a bandage that covers both eyes; close the uninjured eye before bandaging.
f. Give the patient nothing by mouth, never leave him alone, and constantly provide verbal reassurance.
g. Transport immediately.
B. Summary: Emergency care—Eye injuries
1. Review possible assessment findings and emergency care for eye injuries.
2. Review Figure 33-14.
C. Removing contact lenses
1. When to remove
a. If there has been a chemical burn to the eye
b. If the patient is unresponsive and is wearing hard lenses
c. If transport time is lengthy or will be delayed
2. When not to remove
a. If the eyeball is injured (other than a chemical burn)
b. If transport time is short enough to allow emergency department personnel to remove the lens
3. Removing soft contact lenses
a. Place several drops of saline on the lens, then lift off the eye by pinching lens between thumb and forefinger.
b. Use the following procedure.
i. With fingertip on lower lid, pull lid down.
ii. Place index fingertip on lower edge of lens, then slide lens down to white of the eye.
iii. Compress lens between thumb and index finger and remove from eye.
iv. If lens has dehydrated on eye, run sterile saline across it, then slide off cornea and pinch to remove.
v. Store removed lens in water or saline solution.
4. Removing hard contact lenses
a. Separate the eyelids.
b. Position the visible lens over the cornea by manipulating eyelids.
c. Place your thumbs gently on the top and bottom eyelids and open them wide.
d. Press the eyelids down and forward to the edge of the lens.
e. Press the lower eyelid slightly harder and move it under the bottom edge of the lens.
f. Moving the eyelids toward each other, slide the lens out between them.
g. Alternatively, use a contact lens removal kit (commonly available on the ambulance). / Discussion Question
What should you look for in the assessment of an injured eye?
Class Activity
To assess students’ ability to integrate the knowledge in this section, have groups of students write five to ten questions they predict would be on an exam covering this material. Have each group quiz the rest of the class.
Weblink
Go to www.bradybooks.com and click on the mykit link for Prehospital Emergency Care, 9th edition to access web resources on eye injuries, ways to prevent eye injuries, and first aid for eye injuries.
Weblink
Go to www.bradybooks.com
and click on the mykit link for Prehospital Emergency Care, 9th edition to access information about orbital fractures.
Discussion Question
What is the care for an extruded eye?
Knowledge Application
Given a series of scenarios, students should be able to assess and manage a variety of patients with injuries of the eye, face, and neck.
25 / VII. Specific Injuries Involving the Eye, Face, and Neck—Injuries to the Face
A. Assessment and care guidelines
1. Provide emergency care as follows for any apparent facial injury.
a. Establish and maintain in-line spine stabilization.
b. Establishing and maintaining a patent airway
i. Inspect mouth for small fragments of teeth, bits of bone, pieces of flesh, or foreign objects and remove them as thoroughly as possible.
ii. If dentures are whole, leave them in place; if they are broken or loose, remove them and transport with the patient.