What is the initial assessment and management of facial trauma?

Initial Assessment and Management of Facial Trauma

Primary Survey: Life-Threatening Priorities First

Before any facial evaluation, immediately secure airway, breathing, and circulation (ABC), as maxillofacial trauma frequently causes airway compromise through hemorrhage, soft-tissue edema, and loss of facial architecture from fractures. 1, 2, 3

Airway Management Protocol

• Secure the airway immediately with tracheal intubation and continuous end-tidal CO₂ monitoring to prevent hypocapnia-induced cerebral vasoconstriction and brain ischemia. 3
• Whenever possible, intubate the patient while conscious and spontaneously breathing, as this is the safest approach in facial trauma. 4
• Be prepared to change techniques after two unsuccessful attempts with one method; familiarity with multiple airway techniques is essential. 4
• Consider tracheotomy early in patients where immediate or delayed extubation appears unfeasible. 4

Hemodynamic Stabilization

• Maintain systolic blood pressure >110 mmHg, as hypotension below this threshold markedly increases mortality. 3
• Use vasopressors (phenylephrine or norepinephrine) for rapid correction of hypotension rather than waiting for delayed effects from fluid resuscitation. 3
• Avoid hypotensive agents for sedation induction, as even a single episode of SBP <90 mmHg worsens neurological outcomes. 3

Associated Life-Threatening Injuries

• Do not allow severe and disfiguring facial injuries to distract from life-threatening injuries; forces sufficient to fracture facial bones commonly cause shock, brain injury, and coma. 3, 5
• Evaluate for concomitant injuries: 68% of facial fracture patients have intracranial injury, and 11% of mandibular fracture patients have cervical spine injury. 2
• Clear the cervical spine before any facial manipulation. 2

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Secondary Survey: Systematic Facial Examination

Once life-threatening injuries are managed, perform a comprehensive facial assessment that includes the following specific components: 1, 2

Physical Examination Components

• Palpation: Assess all facial bones for step-offs, crepitus, and tenderness. 2
• Visual inspection: Look for asymmetry, deformity, lacerations, contusions, and edema. 2
• Visual acuity testing: Perform full visual acuity assessment and extraocular movement evaluation. 1, 2
• Cranial nerve evaluation: Test all cranial nerves systematically. 1, 2
• Cerebrospinal fluid leak detection: Check for clear rhinorrhea or otorrhea. 1, 2
• Dental occlusion assessment: Evaluate bite alignment, as malocclusion is a direct indicator of midface and mandible injury. 6

Clinical Signs by Anatomic Region

Frontal bone injury is suspected with:

• Tenderness to palpation, contusion, or edema over frontal bone. 3

Midface injury is suspected with:

• Malocclusion (displacement of skeletal structures). 2, 6
• Pain with upper jaw manipulation. 2
• Pain overlying zygoma or zygomatic deformity. 3
• Facial elongation. 2, 3
• Infraorbital nerve paresthesia. 2

Nasal bone injury is suspected with:

• Visible or palpable nasal deformity or tenderness to palpation of nose. 3

Mandibular injury is suspected with:

• Trismus or malocclusion. 3

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Diagnostic Imaging Algorithm

First-Line Imaging

CT maxillofacial without contrast is the gold standard and first-line imaging modality for all patients with acute facial trauma. 2, 3 This provides:

• Superior delineation of osseous and soft-tissue structures. 2, 3
• High resolution that detects subtle nondisplaced fractures. 2, 3
• Multiplanar and 3-D reconstructions critical for preoperative planning. 1
• Rapid acquisition time less reliant on patient positioning than radiography. 1

Complementary Imaging

• CT head without contrast should be obtained concurrently when intracranial injury is suspected, as >33% of frontal sinus fractures have concomitant intracranial injury. 3
• CT angiography of supra-aortic and intracranial arteries should be performed early in patients with risk factors for traumatic dissection, including cervical spine fracture, focal neurological deficit unexplained by brain imaging, Horner syndrome, or basilar skull fractures. 3

Imaging to Avoid

• Plain radiography is insufficient; CT is more sensitive in confirming nasal bone fractures and detecting additional facial injuries. 1
• Chest radiography has no role in initial facial trauma evaluation unless a tooth is absent and aspiration is suspected. 1

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Mandatory Specialty Consultations

Neurosurgery Consultation

• Required when intracranial injury is present (68% of facial fracture patients). 2
• Specifically indicated for orbital wall fractures, as 9% have concomitant intracranial injury. 2
• 8-10% of frontal sinus fractures require surgical intervention for subdural/epidural hematoma. 3

Ophthalmology Consultation

• Mandatory for all orbital fractures to assess visual acuity, extraocular movements, and globe integrity. 2
• Up to 37% of patients with orbital fractures develop diplopia post-operatively due to extraocular muscle entrapment or periorbital edema. 6

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Initial Treatment Measures

Acute Management

• Elevate head of bed for acute maxillary fractures. 2
• Institute sinus precautions (no nose blowing, avoid Valsalva maneuvers). 2
• Administer antibiotic prophylaxis for maxillary fractures and severely contaminated wounds. 2, 7
• Provide coordinated pain management for multiple painful injuries. 2

Wound Management

• Perform wound debridement and primary closure under general anesthesia for extensive contaminated wounds. 7
• Use local and systemic antibiotics for infection control in complex soft tissue trauma. 7

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Critical Pitfalls to Avoid

• Do not miss associated injuries: 75% of frontal bone fractures have additional facial fractures. 3
• Do not overlook vascular injury: Extend CT angiography indications in severe patients where neurological examination is limited, even without classic risk factors. 3
• Do not delay tracheotomy in patients with severe facial trauma where airway patency cannot be reliably maintained. 4
• Document the acute care examination thoroughly before progressing to definitive treatment, as this anticipates problems and is essential for liability considerations. 8