What is the proper workup for facial trauma from a trip and fall while intoxicated?

From the Guidelines

The proper workup for facial trauma from a trip and fall while intoxicated should begin with a thorough primary survey following ATLS principles, focusing on airway, breathing, and circulation. After stabilization, a detailed facial examination should be performed, assessing for asymmetry, malocclusion, facial mobility, sensory deficits, and visual changes. Imaging studies are essential, typically starting with a facial CT scan without contrast to evaluate for fractures of the orbital, maxillary, zygomatic, and mandibular bones, as recommended by the American College of Radiology Appropriateness Criteria 1. Laboratory tests should include a complete blood count, basic metabolic panel, coagulation studies, and blood alcohol level. Additional workup may include a cervical spine CT to rule out concomitant neck injuries, as intoxicated patients cannot reliably report pain. Neurological assessment is crucial, with a low threshold for head CT to evaluate for intracranial hemorrhage, as alcohol can mask symptoms of traumatic brain injury, and CT head may be useful in diagnosing coexisting intracranial injury 1. Ophthalmologic consultation should be obtained for orbital involvement or visual complaints. Wound care includes thorough cleansing, debridement of foreign material, and consideration of tetanus prophylaxis if immunization status is uncertain. The patient should be observed until sober enough for reliable serial examinations, as clinical findings may evolve as intoxication resolves. This comprehensive approach ensures proper identification and management of facial injuries while addressing potential complications related to the intoxicated state.

Some key points to consider in the workup include:

• The use of MDCT to diagnose maxillofacial injuries, which offers superb delineation of osseous and soft-tissue structures 1
• The potential for traumatic vascular injuries, such as blunt cerebrovascular injuries (BCVI), which may require cerebrovascular imaging 1
• The importance of a thorough primary survey and stabilization before proceeding with further evaluation and management.

Overall, the goal of the workup is to ensure proper identification and management of facial injuries, while also addressing potential complications related to the intoxicated state, and prioritizing the patient's morbidity, mortality, and quality of life.

From the Research

Proper Workup for Facial Trauma from a Trip and Fall while Intoxicated

The proper workup for facial trauma from a trip and fall while intoxicated involves several key steps:

• Evaluating the severity of the injury and assessing for any life-threatening conditions
• Conducting a thorough physical examination to identify any facial fractures or soft tissue damage
• Using imaging studies, such as computed tomography (CT) scans, to detect fractures and define their direction, extent, and displacement 2, 3
• Assessing for any adjacent soft tissue damage, such as orbital soft tissue lesions, which may require magnetic resonance imaging (MRI) for evaluation 3

Importance of Imaging in Facial Trauma

Imaging plays a crucial role in the evaluation of facial trauma, with CT scans being the imaging method of choice for detecting facial fractures and defining their morphology and topography 2, 3

• CT scans can provide detailed images of the facial bones and surrounding soft tissues, allowing for accurate diagnosis and treatment planning
• Multiplanar and three-dimensional reconstruction CT images can be useful in assessing soft tissue injuries, such as herniations into fractures of the inferior orbital wall 4

Considerations for Nonoperative Facial Fractures

For nonoperative facial fractures, the use of prophylactic antibiotics is a common practice, although there is limited evidence to support or refute this practice 5

• A study found that there was no difference in the outcome of patients receiving short-term, long-term, or no antibiotic prophylaxis for nonoperative facial fractures 5
• However, the use of protective devices, such as helmets and seatbelts, can decrease the incidence of facial fractures, and alcohol abuse is a significant risk factor for facial trauma 6

Risk Factors for Facial Trauma

Alcohol abuse is a significant risk factor for facial trauma, with a study finding that 39.6% of patients in the motor vehicle crash (MVC) group and 73.5% of patients in the blunt assault (BA) group were legally intoxicated 6

• The lack of protective device use, such as helmets and seatbelts, also correlates with an increased risk of facial fractures 6