What are the initial steps in managing facial injury trauma, including alpha survey and treatment?

Initial Management of Facial Trauma: Primary Survey and Treatment

The initial management of facial trauma must prioritize airway, breathing, and circulation (ABC) stabilization before any facial assessment, followed by systematic evaluation for life-threatening associated injuries, with CT maxillofacial imaging without contrast as the definitive diagnostic modality once the patient is stabilized. 1, 2

Primary Survey: Life-Threatening Priorities

Airway Management

• Maxillofacial trauma can cause airway compromise through hemorrhage, soft-tissue edema, and loss of facial architecture from fractures, requiring immediate intervention. 1
• 42% of severely injured facial trauma patients require intubation, and 14.8% ultimately need tracheostomy during hospitalization. 3
• Airway obstruction ranks as the third most common life-threatening injury in facial fracture patients (after cerebral trauma and hemorrhagic shock), occurring in approximately 17 of 64 patients requiring life-saving intervention. 4

Associated Life-Threatening Injuries

Clinical assessment must systematically evaluate for cerebral trauma first, followed by hemorrhagic shock, airway compromise, and hemopneumothorax, as this sequence reflects the actual frequency and mortality risk. 4

• Cerebral injury occurs in 68% of patients with facial fractures, with subdural hematoma being the most frequent type (43.7% overall cerebral hematoma rate). 5, 3
• Hemorrhagic shock requiring immediate intervention occurs in approximately 30% of patients needing life-saving procedures. 4
• Pulmonary injury is the second most common associated injury (31.1%), with lung contusion predominating. 3
• Cervical spine injury occurs in 7-11% of patients with significant maxillofacial trauma and must be evaluated and cleared. 5
• Blunt cerebrovascular injury (BCVI), though uncommon, carries significant morbidity and mortality if not identified early and requires exclusion in appropriate clinical contexts. 1

Secondary Survey: Facial Assessment

Systematic Facial Examination

Once life-threatening injuries are managed, perform a comprehensive facial evaluation including: 1

• Palpation of all facial bones for step-offs and crepitus
• Visual inspection for asymmetry, deformity, and lacerations
• Full visual acuity testing and extraocular movement assessment
• Cranial nerve evaluation (particularly trigeminal nerve distribution)
• Detection of cerebrospinal fluid leak
• Dental occlusion assessment
• Infraorbital nerve function documentation 5

Clinical Presentation by Region

• Pain with upper jaw manipulation, pain overlying zygoma, facial elongation, malocclusion, or infraorbital nerve paresthesia suggests midface injury. 1
• Frontal bone fractures typically result from high-energy blunt trauma. 2
• Orbital fractures occur in 24.2% of facial trauma patients and are the most common overall facial fracture. 3

Diagnostic Imaging Algorithm

First-Line Imaging

CT maxillofacial without contrast is the first-line imaging modality for facial injury, providing superior delineation of osseous and soft-tissue structures with high resolution that detects subtle nondisplaced fractures. 2

• CT maxillofacial allows multiplanar and 3D image reconstructions, which are critical for characterizing complex fractures and surgical planning. 2
• Three-dimensional reformatted images significantly improve surgeon confidence compared to axial CT images alone. 2
• Plain radiography misses 12% of fractures and is inadequate for surgical planning. 5

Complementary Imaging

• CT head without contrast should complement maxillofacial CT when intracranial injury is suspected, particularly given the 68% incidence of concomitant cerebral injury. 2, 5
• Displaced posterior table frontal bone fractures may indicate underlying dural disruption requiring neurosurgical evaluation. 2
• CTA or MRA should be considered for BCVI screening in high-risk mechanisms, though conventional arteriography remains the reference standard. 1

Mandatory Specialty Consultations

Neurosurgery

• Required when intracranial injury is present (68% of facial fracture patients) and specifically indicated for orbital wall fractures, as 9% have concomitant intracranial injury. 5
• Three of five mortalities in facial trauma patients result from cerebral trauma. 4

Ophthalmology

• Mandatory for all orbital fractures to assess visual acuity, extraocular movements, and globe integrity. 5
• Up to 37% of patients with orbital fractures develop diplopia postoperatively. 5

Otolaryngology/Maxillofacial Surgery

• Consider for frontal sinus fractures and complex nasoethmoidal-orbital injuries. 5
• May assist with airway management in severe midface trauma. 5

Orthopedic Surgery

• Required for associated extremity fractures requiring coordinated management. 6

Initial Treatment Measures

Specific Interventions

• Acute maxillary fractures require elevation of head of bed, sinus precautions, and antibiotic prophylaxis. 6
• Coordinated pain management is essential for multiple painful injuries. 6
• Hospital complication rate reaches 50.3%, primarily involving pulmonary complications, septicemia, renal failure, and severe anemia. 3

Critical Pitfalls to Avoid

• Never allow severe and disfiguring facial injuries to distract from ABC priorities and systematic trauma evaluation. 7, 8
• Cervical spine clearance is essential before manipulation, as 11% of mandibular fracture patients have concomitant cervical spine injury. 5
• Two of five mortalities in facial trauma result from hemorrhagic shock not identified until long after admission, emphasizing the need for repeated systematic assessment. 4
• The ATLS system, while the gold standard, has potential pitfalls specific to maxillofacial injuries that require awareness. 7