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

Acute Facial Trauma Workup in Acute Care Surgery

Immediately secure the airway with tracheal intubation and continuous end-tidal CO2 monitoring, then obtain CT maxillofacial without contrast as first-line imaging, complemented by CT head without contrast when intracranial injury is suspected. 1

Immediate Stabilization (First Priority)

Airway Management

• Airway control is the absolute priority because maxillofacial trauma frequently compromises the airway through hemorrhage, soft-tissue edema, and loss of facial architecture. 1
• Perform tracheal intubation with continuous end-tidal CO2 monitoring to prevent hypocapnia-induced cerebral vasoconstriction and brain ischemia. 1
• Anticipate both difficult endotracheal intubation and difficult mask ventilation in these patients. 2
• When possible, secure the airway in a conscious, spontaneously breathing patient, and change technique after two unsuccessful attempts with one approach. 3

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg prior to measuring cerebral perfusion pressure, as hypotension below this threshold markedly increases mortality. 1
• Use vasopressors (phenylephrine or norepinephrine) for rapid correction of hypotension rather than waiting for delayed effects from fluid resuscitation or sedative adjustment. 1
• Never use hypotensive agents for sedation induction, as even a single episode of hypotension (SBP <90 mmHg) worsens neurological outcomes. 1

Primary Imaging Protocol

First-Line Imaging

• Obtain CT maxillofacial without contrast as the gold standard imaging for all patients with acute facial trauma. 1, 4
• This provides superior delineation of osseous and soft-tissue structures with high resolution to detect subtle nondisplaced fractures. 1
• Multiplanar and 3D image reconstructions are critical for characterizing complex fractures and surgical planning. 4

Complementary Imaging

• Obtain CT head without contrast concurrently, as >33% of frontal sinus fractures have concomitant intracranial injury, and 8-10% require surgical intervention for subdural/epidural hematoma. 1
• This is particularly important since 68% of patients with facial fractures have associated head injuries. 5

Vascular Imaging Indications

Perform CT angiography of supra-aortic and intracranial arteries early if any of these risk factors are present: 1

• Cervical spine fracture
• Focal neurological deficit unexplained by brain imaging
• Horner syndrome (Claude Bernard-Horner syndrome)
• LeFort II or III type facial fractures
• Basilar skull fractures
• Soft tissue lesions at the neck

Extend CT angiography indications in severe patients where neurological examination is limited, even without classic risk factors. 1

Secondary Survey and Clinical Examination

Systematic Facial Examination

After stabilization, perform the following assessments: 1, 5

• Palpation for tenderness, step-offs, and bony deformities
• Visual inspection for contusions, edema, and asymmetry
• Complete visual acuity testing to detect sight-threatening injuries
• Cranial nerve evaluation (particularly infraorbital nerve for midface injury)
• Cerebrospinal fluid leak detection (clear rhinorrhea or otorrhea)
• Dental occlusion assessment (malocclusion indicates mandibular or midface injury)

Region-Specific Clinical Indicators

Frontal Bone Injury: 1

• Tenderness to palpation over frontal bone
• Contusion or edema over frontal bone
• Remember: 75% have additional facial fractures, and forces sufficient to fracture the frontal bone commonly cause shock, brain injury, and coma

Midface Injury: 1

• Malocclusion
• Pain overlying zygoma or zygomatic deformity
• Facial elongation
• Infraorbital nerve paresthesia

Nasal Bone Injury: 1

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

Mandibular Injury: 1

• Trismus
• Malocclusion

Critical Pitfalls to Avoid

• Do not allow severe and disfiguring facial injuries to distract from life-threatening injuries; airway, breathing, and circulation take absolute priority over facial assessment. 1, 5
• 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 and brain injury. 1
• Do not overlook vascular injury: maintain a low threshold for CT angiography in severe patients. 1
• Do not delay imaging: good history and physical examination alone are insufficient to accurately diagnose the full extent of facial trauma. 5
• Do not forget cervical spine precautions until injury is excluded, as this complicates airway management. 2