What is the initial management and workup for a patient with acute facial trauma in an acute care surgery setting?

Acute Facial Trauma Workup in Acute Care Surgery

Following primary ATLS survey and stabilization, obtain CT maxillofacial without contrast as the first-line imaging for all patients with acute facial trauma, complemented by CT head without contrast when intracranial injury is suspected. 1, 2

Initial Stabilization (Primary Survey)

Airway management is the absolute priority and must be secured immediately, as maxillofacial trauma frequently compromises the airway through hemorrhage, soft-tissue edema, and loss of facial architecture. 1

Critical Airway Considerations:

• Perform tracheal intubation with continuous end-tidal CO2 monitoring to prevent hypocapnia-induced cerebral vasoconstriction and brain ischemia. 1
• Anticipate difficult intubation and difficult mask ventilation in facial trauma patients; secure the airway in a conscious, spontaneously breathing patient whenever possible. 3, 4
• Maintain systolic blood pressure >110 mmHg prior to measuring cerebral perfusion pressure, as hypotension below this threshold markedly increases mortality. 1
• Use vasopressors (phenylephrine, norepinephrine) for rapid correction of hypotension rather than waiting for delayed effects from fluid resuscitation or sedative adjustment. 1

Secondary Survey: Focused Clinical Examination

After stabilization, perform a systematic facial examination including palpation, visual inspection, full visual acuity testing, cranial nerve evaluation, cerebrospinal fluid leak detection, and dental occlusion assessment. 1, 5

Key Clinical Indicators by Region:

Frontal bone injury (suspect if): 1

• Tenderness to palpation, contusion, or edema over frontal bone

Midface injury (suspect if): 1, 5

• Malocclusion (direct indicator of midface/mandible displacement) 5
• Pain with upper jaw manipulation
• Pain overlying zygoma or zygomatic deformity
• Facial elongation
• Infraorbital nerve paresthesia

Nasal bone injury (suspect if): 1

• Visible or palpable nasal deformity
• Tenderness to palpation of nose
• Epistaxis

Mandibular injury (suspect if): 1

• Trismus or malocclusion
• Gingival or mucosal hemorrhage
• Loose, fractured, or displaced teeth

Imaging Protocol

First-Line Imaging:

CT maxillofacial without contrast is the gold standard, providing superior delineation of osseous and soft-tissue structures with high resolution to detect subtle nondisplaced fractures. 1, 2

Key advantages of CT maxillofacial: 1, 2

• Thin-section acquisitions detect subtle nondisplaced fractures
• Multiplanar and 3D reconstructions characterize complex fractures
• 3D reformations are critical for surgical planning and significantly improve surgeon confidence
• Faster acquisition than radiography or MRI
• Less reliant on patient positioning

Complementary Imaging:

CT head without contrast is complementary and should be obtained concurrently, as >33% of frontal sinus fractures have concomitant intracranial injury, and 8-10% require surgical intervention for subdural/epidural hematoma. 1, 2

CT angiography of supra-aortic and intracranial arteries should be performed early in patients with the following risk factors for traumatic dissection: 1

• Cervical spine fracture
• Focal neurological deficit unexplained by brain imaging
• Horner syndrome
• LeFort II or III facial fractures
• Basilar skull fractures
• Soft tissue neck lesions

Imaging NOT Recommended Acutely:

MRI head has no role in initial acute facial trauma workup; it is reserved for subacute or chronic head trauma evaluation. 1

CT with IV contrast does not aid in detection of acute head or facial injury. 1

Critical Pitfalls to Avoid

Do not allow severe and disfiguring facial injuries to distract from life-threatening injuries; always follow ATLS protocol first. 6

Do not use hypotensive agents for sedation induction, as even a single episode of hypotension (SBP <90 mmHg) worsens neurological outcomes. 1

Do not miss associated injuries: 75% of frontal bone fractures have additional facial fractures, and forces sufficient to fracture the frontal bone commonly cause shock, brain injury, and coma. 1

Do not overlook vascular injury: extend CT angiography indications in severe patients where neurological examination is limited, even without classic risk factors. 1

Do not assume isolated nasal fractures require CT; these are diagnosed clinically through history and examination, with closed reduction as standard treatment. 6

Multidisciplinary Coordination

Designate oral and maxillofacial surgery as the coordinating specialty to guide the complex acute care and treatment process, with involvement from otorhinolaryngology, plastic surgery, ophthalmology, and dentistry as needed. 7