From the Guidelines
For a penetrating trauma to the temple with associated periorbital swelling and epistaxis, immediate medical attention at a trauma center is essential to prevent morbidity, mortality, and to improve quality of life. The management of such an injury prioritizes ensuring the patient's airway, breathing, and circulation (ABCs) are stable, followed by specific interventions for the trauma.
Initial Assessment and Stabilization
- Ensure the ABCs are stable.
- Apply direct pressure to external bleeding sites using sterile gauze.
- Do not remove any impaled objects as they may be tamponading major vessels.
Management of Nosebleed
- Have the patient sit upright leaning slightly forward.
- Pinch the soft part of the nose for 10-15 minutes continuously, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
- Apply ice packs to the bridge of the nose.
Management of Orbital Swelling
- Apply cold compresses for 20 minutes every hour while awake for the first 24-48 hours.
- The patient requires a thorough examination, including vision testing, refraction, pupillary examination, IOP measurement, confrontational visual field testing, slit-lamp examination, and a dilated or undilated fundus examination, as outlined in the adult strabismus preferred practice pattern 1.
Diagnostic Imaging
- Urgent CT imaging is necessary to assess for skull fracture, intracranial hemorrhage, orbital fracture, and vascular injury, as these conditions can significantly impact morbidity, mortality, and quality of life.
Infection Prevention
- Antibiotics, such as ceftriaxone 2g IV daily plus metronidazole 500mg IV every 8 hours, are typically needed to prevent infection.
- Tetanus prophylaxis should be administered if not up to date.
Specialized Evaluation
- The combination of orbital swelling and nosebleed suggests possible extension of injury into the orbital and nasal cavities, which may indicate a more complex injury pattern requiring neurosurgical, ophthalmological, and maxillofacial surgical evaluation, as highlighted in the management of facial trauma following primary survey 1.
- Determining the cause of diplopia after orbital trauma requires a detailed history, examination, and often imaging, considering the etiology may be multifactorial, including direct damage to the extraocular muscles and surrounding orbital structures or contemporaneous trauma to the central nervous system 1.
Given the potential for significant morbidity and mortality associated with penetrating trauma to the temple, immediate and comprehensive management is crucial to improve patient outcomes.
From the Research
Management of Penetrating Trauma to the Temple
The management of a penetrating trauma to the temple with associated periorbital swelling and epistaxis involves a comprehensive approach.
- The treatment depends on the route, depth, and location of cranial penetration, as well as the presence of any associated injuries 2.
- In cases of orbital gunshot wounds, the preservation of visual function depends on the projectile channel and the characteristics of the gun and bullet 3.
- Surgical management may involve collaboration between ophthalmologists, maxillofacial surgeons, and neurosurgeons in specialized centers 3.
- In some cases, patients may present with multiple trauma, and prompt interdisciplinary treatment is necessary 3.
Associated Injuries
- Periorbital swelling can be caused by various factors, including forceful sneezing, which can lead to orbital fractures and subcutaneous emphysema 4.
- Orbital compartment syndrome is a rare condition that can occur after frontotemporal craniotomy, characterized by increased intraorbital pressure and hypoperfusion of critical neural structures 5.
- The treatment of orbital compartment syndrome involves emergency lateral canthotomy and cantholysis to reduce intraorbital pressure 5.