From the Guidelines
For a patient with a fall who is unresponsive with facial fractures, immediate stabilization of the airway, breathing, and circulation is the top priority, as emphasized by the American College of Radiology in their 2022 guidelines 1.
Initial Assessment and Stabilization
The patient's airway should be secured first, considering intubation if there's any compromise, as facial fractures can cause airway obstruction from bleeding, edema, or bone fragments. A rapid neurological assessment including Glasgow Coma Scale and pupillary responses should be performed to evaluate the severity of brain injury.
Imaging and Diagnostic Tests
A non-contrast head CT scan should be ordered to assess for intracranial hemorrhage, brain contusion, or skull fractures, as recommended by the ACR Appropriateness Criteria for imaging of facial trauma following primary survey 1. This should be followed by facial CT scans to evaluate the extent of facial fractures. Additional imaging should include cervical spine CT to rule out associated neck injuries, given the high incidence of concomitant cervical spine injuries in patients with maxillofacial injuries 1.
Laboratory Tests and Consultations
Laboratory tests should include complete blood count, coagulation studies, electrolytes, blood glucose, and toxicology screening. Consultations with neurosurgery for head injury management and maxillofacial surgery for facial fracture repair are essential. If the patient remains hemodynamically unstable, consider additional trauma imaging such as chest and abdominal CT scans to identify other injuries, as the presence of facial fractures can indicate significant trauma involving multiple systems 1.
Comprehensive Approach
This comprehensive approach is necessary because unresponsiveness after a fall suggests significant trauma that may involve multiple systems, and facial fractures often coexist with other serious injuries that require prompt identification and management, as highlighted in the ACR Appropriateness Criteria for imaging of facial trauma following primary survey 1.
From the Research
Initial Assessment and Management
- The initial assessment of a patient with a fall, presenting as unresponsive with facial fractures, should focus on managing the airway, as compromised airway can lead to death 2.
- Evaluation of the patient's airway, breathing, and circulation (ABCs) is crucial, and intubation may be necessary to secure the airway 2.
- The choice of intubation method depends on the patient's situation and the expertise of the trauma team, with options including endotracheal intubation, nasotracheal intubation, tracheotomies, submental, and submandibular intubation techniques 2.
Diagnostic Imaging
- Spiral CT scans with reformations are recommended for the diagnosis of cervical spine fractures, as they provide a complete image of injuries to bony structures and can help avoid mistakes in the interpretation of injuries 3.
- Conventional radiographs may not be sufficient for assessing cervical spine injuries, especially in polytrauma patients 3.
- CT scans can also be useful in evaluating facial fractures, including frontal, orbital, nasal, maxillofacial, and mandibular fractures 4.
Concomitant Injuries and Management
- Patients with facial fractures due to falls are at risk of concomitant injuries, including cervical spine fractures, skull fractures, intracerebral hemorrhage, and long bone fractures 5.
- A thorough evaluation of the patient's overall condition, including concomitant injuries, is essential for developing an appropriate management plan 5.
- Surgical management of facial fractures may be necessary, and the approach should be tailored to the individual patient's needs, taking into account their age, comorbidities, and overall condition 5.
- Life-threatening injuries associated with facial fractures, such as airway compromise, hemorrhagic shock, and cerebral trauma, require prompt identification and management 6.