What is the management approach for acute facial swelling in an Emergency Room (ER) setting?

Management of Acute Facial Swelling in the Emergency Room

The management of acute facial swelling in the emergency room should follow the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure), with immediate assessment of airway patency as the top priority since facial swelling can rapidly progress to airway compromise. 1

Initial Assessment and Stabilization

Airway Management

• Assess for signs of airway compromise immediately:

  • Stridor, voice changes, difficulty breathing, respiratory distress 2
  • Presence of soot around mouth/nose, singed nasal hairs (in burn cases) 2
  • Dysphagia, drooling (suggesting potential airway obstruction) 2

• Airway intervention indications:

  • Intubate immediately if signs of airway obstruction are present 2
  • Consider intubation for patients with:
    • Deep and circular burns on the neck
    • Symptoms of airway obstruction (voice change, stridor, laryngeal dyspnea)
    • Very extensive burns (TBSA >40%) 2
  • Do not routinely intubate patients with only face/neck burns without other concerning features 2

• Position patient upright if no trauma and administer supplemental oxygen 2

Breathing and Circulation

• Provide supplemental oxygen to maintain SpO2 >94% 2
• Monitor vital signs continuously 3
• Establish IV access for fluid administration if needed 3
• Consider cardiac monitoring in cases of anaphylaxis or electrical burns 3

Diagnosis and Cause-Specific Management

1. Allergic/Anaphylactic Causes

• For anaphylaxis:

  • Administer epinephrine 0.3-0.5mg IM (adult) or 0.15mg IM (child) in anterolateral thigh
  • Provide H1 antihistamines and corticosteroids
  • Consider H2 blockers as adjunctive therapy
  • Monitor for biphasic reactions (up to 24 hours) 3

• For angioedema:

  • Distinguish between histamine-mediated and bradykinin-mediated types 4
  • For histamine-mediated: antihistamines, corticosteroids, epinephrine if severe
  • For bradykinin-mediated (e.g., ACE inhibitor-induced): discontinue offending medication, consider icatibant or C1 inhibitor concentrate if available 4

2. Burn-Related Facial Swelling

• Cool thermal burns with running water at room temperature for 10-20 minutes 2, 3
• Do not apply ice directly to the skin 2
• For chemical burns: irrigate with copious amounts of water
• For electrical burns: monitor for cardiac arrhythmias 3
• Wound care:
  • Leave blisters intact unless specifically indicated 3
  • Apply a thin layer of antibiotic ointment if no known allergies 3
  • Cover with sterile, non-adherent dressing 3
• Pain management: provide adequate analgesia with multimodal approach (acetaminophen, NSAIDs, opioids if severe) 3

3. Infectious Causes

• For cellulitis/erysipelas:

  • Obtain cultures if possible before starting antibiotics
  • Start empiric antibiotics covering Streptococcus and Staphylococcus (e.g., cefazolin or clindamycin) 3
  • Elevate affected area if possible

• For odontogenic infections:

  • Urgent dental/maxillofacial consultation
  • Broad-spectrum antibiotics covering oral flora
  • Consider incision and drainage if abscess present

• For necrotizing fasciitis:

  • Surgical consultation for immediate debridement
  • Broad-spectrum antibiotics including coverage for anaerobes
  • Aggressive fluid resuscitation 3

4. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

• Discontinue suspected causative medications

• Wound care:

  • Leave detached epidermis in situ as biological dressing 2
  • Decompress blisters by piercing and expression or aspiration 2
  • Apply white soft paraffin ointment to lips every 2 hours 2
  • Consider silicone dressings for eroded areas 2

• Pain management:

  • Use validated pain assessment tools 2
  • Administer adequate analgesia (IV opioid infusions if not tolerating oral) 2
  • Consider patient-controlled analgesia 2

• Mouth care:

  • Daily oral review during acute phase 2
  • Clean mouth daily with warm saline mouthwashes 2
  • Apply anti-inflammatory oral rinse containing benzydamine hydrochloride 2

• Eye care:

  • Urgent ophthalmology review 2
  • Apply ocular lubricant every 2 hours 2
  • Daily ophthalmological assessment 2

5. Post-Thyroid Surgery Hematoma

• Immediate management for airway compromise:
  • Follow "SCOOP" approach: Skin exposure; Cut sutures; Open skin; Open muscles; Pack wound 2
  • Call for senior surgical and anesthetic help immediately 2
  • Administer supplemental oxygen and position patient head-up 2
  • Consider IV dexamethasone and tranexamic acid 2

Special Considerations

Pediatric Patients

• Lower threshold for intervention as children can deteriorate rapidly
• Adjust medication doses based on weight
• Consider congenital causes in non-progressive facial swelling 5

Monitoring and Disposition

• Continuous monitoring of vital signs and airway status
• Reassess frequently for signs of deterioration
• Disposition decisions:
  • ICU admission for:
    • Airway concerns
    • Extensive facial burns
    • Stevens-Johnson syndrome/TEN
    • Severe infections with systemic symptoms
  • Consider transfer to specialized centers (burn units, dermatology units) when appropriate 2

Common Pitfalls to Avoid

• Delayed recognition of airway compromise - maintain high vigilance for subtle signs
• Underestimating progression - facial swelling can worsen rapidly
• Excessive fluid administration in burns - can worsen airway swelling 2
• Unnecessary intubation in facial burns without airway compromise 2
• Failure to consider rare but serious causes like necrotizing fasciitis or angioedema
• Delayed specialist consultation (ENT, maxillofacial, dermatology, ophthalmology)

By following this systematic approach to acute facial swelling in the emergency room, clinicians can ensure appropriate management that prioritizes airway protection while addressing the underlying cause of the swelling.