Bones

With a possible cervical spine injury, the nurse opens the airway by placing fingers behind both angles of the mandible and lifting the jaw forward, without tilting the head. Lifting the jaw pulls the tongue off the back of the throat while the neck stays still.

A broken mandible or maxilla bleeds into the mouth, swells, and can let the tongue or loose bone fall backward. The nurse sits the patient up if the spine allows, suctions blood, and watches for stridor, drooling, and a voice change. Nothing goes through the nose (no nasogastric tube, no nasal airway) when the midface is broken, because the fracture may open into the skull base.

After a jaw is wired shut, the nurse keeps wire cutters (or scissors for elastic bands) and suction at the bedside and gives antiemetics on time. If the patient vomits, the nurse turns them onto their side and suctions first; the wires are cut only if the airway cannot be cleared. The patient goes home with cutters and is taught the same rule.

After a blow to the back of the head, the nurse checks level of consciousness and pupils and looks for bruising behind the ear or around the eyes and clear drainage from the nose or ear, testing the drainage with a halo on gauze or a glucose check. Drainage is never packed or plugged, and no nasogastric tube, nasal suctioning, or nose-blowing is allowed, because a tube can pass through a fractured skull base into the brain and leaking fluid means an open path for infection. Any drop in level of consciousness, new pupil change, or worsening headache and vomiting is reported at once as a sign of bleeding or rising pressure inside the skull.

Bruising over the mastoid (Battle sign), bruising around both eyes (raccoon eyes), or clear fluid from the nose or ear point to a fracture through the skull base. The bruising may not appear for a day or more, so its absence soon after the injury does not rule out a fracture. A halo ring on gauze or drainage that tests positive for glucose suggests spinal fluid, and the nurse reports it promptly. Nothing goes through the nose: no nasogastric tube, no nasal suction, no nasopharyngeal airway, and the patient is told not to blow the nose.

Because the closed skull cannot expand, a change in level of consciousness is the earliest sign of rising pressure, and the nurse reports it without waiting for vital signs to change. Rising systolic pressure with a widening pulse pressure, a slow heart rate, and irregular breathing (Cushing triad) are late signs. The nurse keeps the head of the bed raised about 30 degrees with the head and neck midline, and avoids straining, coughing, and sharp hip or neck flexion.

Leaking spinal fluid is allowed to drain onto a loose sterile dressing that is changed as it gets wet. Packing the nose or ear traps fluid at an open path to the brain and raises the risk of meningitis, so the nurse never plugs the leak and watches for fever, stiff neck, and worsening headache.