Facial Trauma

OVERVIEW

Those with facial injuries have a high chance of having other serious injuries:

  1. TBI
  2. airway obstruction
  3. pulmonary contusion
  4. aspiration
  • mostly blunt

RISK FACTORS

  • MVA
  • non-restrained
  • no airbags
  • ETOH

TYPES OF INJURY

  • mandibular #
  • mid-facial # (Le Fort I -> III #)
  • TMJ disruption
  • zygomatic, orbital and nasal #
  • soft tissue injuries
  • haemorrhage
  • associated injuries: BOS #, TBI, cervical spine #, carotid injury

MANDIBULAR #

  • fractures at the vunerable points (ramus, body at level of 1st and 2nd molar)
  • bilateral # can precipitate airway obstruction from posterior displacement of tongue

MIDFACE #

  • the nasal cavity, paranasal sinuses and orbits act as a series of compartments that progressively collapse and absorb energy protecting the brain, spinal cord and other vital structures.

Le Fort I

  • # involving the maxilla at the level of the nasal fossa
  • horizontal plane at the level of the nose
  • palate-facial separation

Le Fort II

  • maxilla, nasal bones and medial aspect of the orbit involved -> freely mobile, pyramidal-shaped portion of the maxilla (pyramidal disjunction).
  • fracture line extend from the lower nasal bridge through medial wall of the orbit, crosses the zygomaticomaxillary process.

Le Fort III

  • craniofacial disjunction -> fracture line runs parallel to the base of the skull which separates the midfacial skeleton from the cranium (involves the ethmoid bone and cribriform plate at the BOS)
  • fracture line extends through the upper nasal bridge and most of the orbit across the zygomatic arch.

TEMPROMANDIBULAR JOINT

  • mechanical impairment may result from condylar or zygomatic arch fracture and can prevent jaw opening (even when paralyzed).

ORBITAL FRACTURES

  • severity can vary
  • oedema and ecchymosis -> subconjunctival haemorrhage and loss of vision -> ocular rupture
  • blow out fracture occurs when pressure directly applied to eye with fracture of inferior bony structures (enophthalmos, diplopia, impaired eye movement, infraorbital hypoesthesia)

NASAL FRACTURES

  • prime concerns are epistaxis and septal haematoma

SOFT TISSUE INJURIES

  • abrasions, contusions, lacerations
  • evolving oedema over 24-48 hours can be massive and potentially threaten airway patency

SEEK ASSOCIATED INJURIES

  • Base of skull fracture
  • CSF rhinorrhoea (anterior or middle fossa BOS #)
  • carotid-cavernous fistula (pulsatile exophthalmos, orbital bruit)
  • TBI
  • cervical spinal injury
  • traumatic occlusion or dissection of internal carotid artery or vertebral artery
  • thoracic trauma
  • abdominal trauma

MANAGEMENT

Resuscitate

  • assess and secure airway (may require cricothyroidotomy/tracheostomy)
  • stop bleeding (nasal tampons)

Specific

  • open, contaminated wounds: irrigation, debridement, removal of foreign bodies and closure within 24 hours, prophylactic antiobiotics
  • early surgery if orbital injury with optic nerve compression is present.
  • tetanus
  • prophylactic antibiotics for CSF leak are not indicated (still controversial)
  • internal fixation usually performed at 4-10 days once swelling has settled

References and Links

FOAM and web resources

Journal articles

  • Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: Advanced trauma life support. Emerg Med J. 2006 Oct;23(10):796-7. PMC2579603. (Part 1 of 6 on facial injuries)
  • Kretlow JD, McKnight AJ, Izaddoost SA. Facial soft tissue trauma. Semin Plast Surg. 2010 Nov;24(4):348-56. PMC3324223.
  • Lynham AJ, Hirst JP, Cosson JA, Chapman PJ, McEniery P. Emergency department management of maxillofacial trauma. Emerg Med Australas. 2004 Feb;16(1):7-12. PMID: 15239748.
  • Perry M, Dancey A, Mireskandari K, Oakley P, Davies S, Cameron M. Emergency care in facial trauma–a maxillofacial and ophthalmic perspective. Injury. 2005 Aug;36(8):875-96. PMID: 16023907.
  • Perry M. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 1: dilemmas in the management of the multiply injured patient with coexisting facial injuries. Int J Oral Maxillofac Surg. 2008 Mar;37(3):209-14. PMID: 18178381.
  • Perry M, Morris C. Advanced trauma life support (ATLS) and facial trauma: can one size fit all? Part 2: ATLS, maxillofacial injuries and airway management dilemmas. Int J Oral Maxillofac Surg. 2008 Apr;37(4):309-20. PMID: 18207702.
  • Perry M, O’Hare J, Porter G. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient. Int J Oral Maxillofac Surg. 2008 May;37(5):405-14. PMID: 18262768.
  • Perry M, Moutray T. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 4: ‘can the patient see?’ Timely diagnosis, dilemmas and pitfalls in the multiply injured, poorly responsive/unresponsive patient. Int J Oral Maxillofac Surg. 2008 Jun;37(6):505-14. PMID: 18295453.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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