Is emergent transport required for a closed blowout fracture?

Closed Blowout Fracture Transport Decision

A closed blowout fracture does NOT require emergent transport in most cases, but immediate emergency activation is mandatory if the patient exhibits signs of oculocardiac reflex (bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness) or muscle entrapment. 1, 2

Immediate Emergency Transport Indications

You must activate emergency transport immediately if ANY of the following are present:

• Bradycardia, heart block, or cardiac dysrhythmias indicating oculocardiac reflex from muscle entrapment 1
• Dizziness, nausea, vomiting, or loss of consciousness suggesting trigeminovagal reflex activation 1
• Severe restriction of eye movement with positive forced duction testing indicating entrapped extraocular muscle 2
• Vision-threatening conditions (complete vision loss occurs in 5.5% of one eye in facial fractures) 2

The oculocardiac reflex is triggered when orbital trauma causes muscle entrapment, creating a trigeminovagal reflex arc that produces negative chronotropic cardiac effects. 1 This represents a true emergency requiring immediate surgical intervention. 2

Urgent Transport (Within Hours to Days)

Transport urgently but not emergently for:

• Symptomatic diplopia with positive forced ductions or CT evidence of entrapment (surgery needed within 2 weeks) 2
• "White-eyed blowout fracture" in pediatric patients with minimal external signs but significant internal entrapment 2, 3
• Large floor fractures with significant fat or periorbital tissue entrapment 2
• Progressive infraorbital hypoesthesia 2

Non-Emergent Transport

Standard transport is appropriate for:

• Minimal diplopia with good ocular motility 2
• No significant enophthalmos or hypoglobus 2
• Stable vital signs without cardiac symptoms 1
• Absence of muscle entrapment on examination 2

These patients can be observed conservatively for 4-6 months, as many cases resolve spontaneously. 2 Even without surgery, blowout fractures often do not produce serious sequelae. 4

Critical Assessment Points

Perform these evaluations to determine transport urgency:

• Vital sign monitoring for bradycardia or dysrhythmia during orbital manipulation 1
• Forced duction testing to confirm muscle entrapment versus paresis 2
• Assess for periorbital air inflation when patient blows nose (pathognomonic sign) 4, 5
• Check infraorbital nerve sensation for numbness distribution 4

Common Pitfalls to Avoid

• Do not assume minimal external signs mean minimal injury - white-eyed blowout fractures in children can have severe entrapment despite minimal swelling 3
• Do not delay transport if cardiac symptoms develop - oculocardiac reflex requires immediate surgical decompression 1, 2
• Do not rely solely on standard radiographs - CT imaging is necessary for definitive diagnosis and surgical planning 2, 5
• Do not rush to surgery in stable patients - 37% still have persistent diplopia postoperatively, so conservative management is often appropriate 2

The provided general fracture guidelines 6 address extremity fractures and are not applicable to orbital fractures, which have unique neurovascular considerations requiring specialized ophthalmologic assessment rather than general trauma protocols.