What is the most appropriate management for a patient 3 days post-accident with a Glasgow Coma Scale (GCS) score of 6/15 and facial palsy?

Management of Post-Traumatic Facial Palsy with Severe Brain Injury (GCS 6/15)

The most appropriate immediate management is no immediate facial nerve intervention (option b); the priority is securing the airway, stabilizing the patient, and managing the severe traumatic brain injury, with facial palsy management deferred until neurological stabilization occurs. 1

Critical First Priority: Airway and Brain Injury Management

This patient requires immediate endotracheal intubation because the GCS of 6/15 is well below the threshold of 8/15 for airway protection. 1, 2

• Intubation must be performed without delay in patients with GCS ≤8 to prevent hypoxemia and secondary brain injury. 1
• During intubation, maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg to ensure adequate cerebral perfusion. 1
• Target normocapnia (PaCO₂ 4.5-5.0 kPa) and avoid hyperventilation except as a brief life-saving measure for impending herniation. 1

Immediate Neurological Assessment Required

After airway stabilization, urgent neurological evaluation is mandatory:

• Perform pupillary examination and obtain brain CT scan immediately to determine severity of brain damage and identify life-threatening intracranial lesions. 1
• Assess for surgical indications including symptomatic extradural hematoma, significant subdural hematoma (>5mm thickness with >5mm midline shift), or acute hydrocephalus. 1, 3
• Consider ICP monitoring in comatose patients with radiological signs of intracranial hypertension. 1

Why Facial Decompression is NOT Appropriate Now

Facial nerve decompression (option c) is contraindicated at this stage for multiple critical reasons:

• The patient's devastating brain injury (GCS 6/15) requires stabilization over 24-72 hours before any prognostication or non-life-saving interventions. 1
• Surgical facial nerve decompression timing and outcomes lack strong evidence, and no controlled studies support emergency decompression in the acute trauma setting. 1
• The facial palsy may be due to direct cranial nerve injury from temporal bone fracture, which often shows delayed onset and can recover spontaneously without surgery. 4
• High-resolution CT of temporal bones and electrodiagnostic testing (EMG) are needed to determine the site and severity of facial nerve injury, but these are not urgent in the first 24-72 hours. 4, 5

Observation Period is Essential

A period of physiological stabilization (24-72 hours) is required before any decisions about facial nerve intervention:

• The key observation during this period is repeated clinical monitoring of conscious level (GCS) and pupillary reactions after physiological stability is achieved. 1
• Facial nerve function should be reassessed once confounders are treated, including drugs, seizures, physiological derangement (hypotension, hypoxemia), and direct cranial nerve injury. 1
• If the patient shows neurological improvement, then facial nerve evaluation with high-resolution CT and electrodiagnostic studies can be performed. 4, 5

Why Other Options Are Incorrect

Physiotherapy (option a) has no role in acute management:

• Physical therapy for facial palsy shows no significant benefit over spontaneous recovery in systematic reviews. 1
• No standardized therapy modalities exist, and there is no evidence supporting benefit or harm of physical therapy for Bell's palsy or traumatic facial palsy. 1

EMG (option d) is not immediate management:

• Electrodiagnostic testing is useful for confirming bilateral facial nerve injury and assessing for axonal degeneration, but it is performed after initial stabilization, not as immediate management. 4
• EMG is typically done 3-7 days post-injury to allow Wallerian degeneration to occur, making it more diagnostically useful. 4

Subsequent Facial Nerve Management (After Stabilization)

If the patient survives and stabilizes neurologically, then facial nerve evaluation proceeds:

• Obtain high-resolution CT of temporal bones to identify fractures involving the fallopian canal. 4, 5
• Perform electrodiagnostic testing to assess for significant distal axonal degeneration. 4
• Consider short course of corticosteroids (prednisone) if no contraindications exist, though evidence in trauma is limited. 6, 4
• Surgical decompression via transcanal endoscopic approach may be considered if there is radiologic evidence of tympanic segment or perigeniculate involvement with >90% degeneration on EMG, but this is typically done 2-3 weeks post-injury, not acutely. 5

Eye Protection is the Only Immediate Facial Palsy Concern

While not listed as an option, corneal protection is the only facial palsy-related intervention needed acutely:

• Patients with incomplete eye closure require referral to ophthalmology and strategies for eye closure (taping) and moisturization (artificial tears, eye ointment). 1
• This prevents serious ocular complications in severe facial paresis with lagophthalmos. 1

Common Pitfall to Avoid

Do not pursue facial nerve decompression in the acute setting (first 24-72 hours) when the patient has severe traumatic brain injury requiring intensive care. The devastating brain injury takes absolute priority, and facial nerve outcomes cannot be accurately predicted until neurological stabilization occurs. 1