EMR Guide to Facial Trauma: Airway Management, Bleeding Control, and Injury Assessment
/Facial Trauma - Assessment and Treatment
Tradesmen with laceration to face
Facial trauma refers to injuries involving damage to the bones or soft tissue of the face. These injuries can occur due to a variety of causes such as motor vehicle accidents, assaults (including gunshots), sports injuries, falls, chemical exposures, thermal burns, or animal bites. Because the human face is complex and contains many critical structures, such as bones, blood vessels, nerves, muscles, and sensory organs, untreated facial trauma can lead to permanent functional loss (such as problems with seeing, chewing, speaking, or swallowing) and severe disfigurement. Therefore, rapid and effective assessment and treatment are crucial in preventing long-term complications.
Facial trauma can be categorized into two primary categories: bone and soft tissue injuries. Depending on the type and severity of the trauma, the treatment and management priorities will differ. Let’s explore how to assess, treat, and what to expect when dealing with facial trauma in an emergency setting.
Key Considerations for EMRs Responding to Facial Trauma
When an EMR encounters a patient with facial trauma, the first priority is to assess the patient's airway, control bleeding, and assess for any associated injuries. This is especially critical because facial trauma can lead to airway compromise and severe bleeding, both of which are life-threatening.
Airway Management: The First Priority
One of the most critical aspects of treating facial trauma is securing the airway. The face houses the upper airway structures, and injuries to the face can easily result in obstruction. Up to 42% of patients with severe maxillofacial trauma may require intubation. If airway compromise is not addressed, it can result in hypoxia, shock, or even death.
Airway compromise in facial trauma typically occurs due to:
Soiling of the airway: Blood, vomit, or other debris can obstruct the airway, especially in patients with severe bleeding or emesis.
Obstruction: This can result from displaced soft tissue (such as the tongue), facial swelling, or foreign bodies (like dislodged teeth).
When assessing for airway compromise, EMRs should prioritize maintaining patency and anticipate potential difficulties with bag-mask ventilation due to the altered facial anatomy. For example, in Le Fort II and Le Fort III fractures, which cause significant facial displacement, it can be challenging to achieve a proper seal with a mask. If bag-mask ventilation becomes difficult, consider using a supraglottic airway device as a temporary bridge to more definitive airway management until advanced care can be provided.
Controlling Bleeding
Facial injuries, especially those involving trauma to the nose, mouth, or eyes, often result in significant bleeding. The face is highly vascular, so controlling bleeding early is vital to avoid shock and further complications. The steps to control bleeding are:
Direct Pressure: Apply direct, firm pressure over the bleeding site using sterile gauze or a clean cloth.
Elevation: If possible, elevate the patient’s head to minimize blood flow to the injury site.
Pressure Points: Use pressure points such as the carotid artery or facial artery to control hemorrhage when direct pressure is insufficient.
Hemostatic Agents: In severe cases, use hemostatic agents or dressings to assist in clotting and bleeding control.
Assessing Associated Injuries
Facial trauma often occurs as part of multi-system injuries. Once the airway is secured and bleeding is controlled, assess for other possible injuries, such as:
Head injury: Concussions, skull fractures, or intracranial hemorrhages are common in traumatic incidents that involve facial injury.
Spinal injury: Always suspect cervical spine injury in any trauma patient, especially those with altered mental status or facial fractures.
Dental injuries: Dislodged teeth or fractures to the jaw may occur in conjunction with facial trauma and may require specific management.
Eye injuries: Damage to the eyes, such as orbital fractures, corneal abrasions, or foreign bodies, should be suspected and managed accordingly.
Types of Maxillofacial Fractures
Facial fractures can be complex, and different fractures require different management strategies. Some common types of fractures include:
Le Fort Fractures:
Le Fort I: A horizontal fracture of the maxilla (upper jaw), often associated with palate and teeth displacement.
Le Fort II: A pyramidal fracture involving the maxilla, nasal bones, and orbit, which may cause significant facial deformity.
Le Fort III: A complex fracture involving the maxilla, zygomatic bones, and orbit, resulting in severe facial disfiguration and airway compromise.
Orbital Fractures: These fractures affect the bony orbit surrounding the eye. They may lead to eye injuries and double vision, requiring immediate attention to preserve vision.
Nasal Fractures: Fractures to the nasal bones are common and often associated with bleeding and airway obstruction due to the nasal passages becoming blocked with blood.
Mandible (Jaw) Fractures: Fractures of the mandible may affect the ability to chew, swallow, and speak. In some cases, the fractured jaw may obstruct the airway.
Treatment Considerations
The management of facial trauma depends on the type and severity of the injury. However, the basic principles of care involve airway management, bleeding control, and stabilization of fractures.
Airway Management
As previously mentioned, ensuring airway patency is paramount in facial trauma cases. If there is any suspicion of airway compromise, early intubation should be performed. In some cases, a supraglottic airway device may be used to bridge the gap before definitive airway management. In more severe cases, surgical airway interventions may be required.
Fracture Stabilization
Fractures, particularly those involving the mandible, maxilla, or facial bones, may need to be stabilized. The use of splints, jaw wiring, or other external fixation devices can help keep the fractures in place until surgical intervention by a plastic or maxillofacial surgeon can be performed.
Transportation
Facial trauma victims, particularly those with suspected airway compromise, require rapid transport to a hospital with appropriate resources for managing complex trauma. Transport should be done with the patient’s head elevated and airway support in place to prevent further compromise.
Conclusion
Facial trauma is a serious medical condition that requires prompt and effective intervention. As an EMR, your role in ensuring airway management, bleeding control, and assessment of associated injuries is vital in improving patient outcomes. While facial trauma may be life-threatening, the coordinated efforts of EMRs, emergency doctors, and specialists such as plastic and reconstructive surgeons can significantly reduce the risk of permanent functional loss and disfigurement. By understanding the anatomy of the face, the types of fractures, and the treatment strategies, you can provide critical care that saves lives and improves the long-term recovery of those injured in traumatic incidents.
Stay informed, stay prepared, and continue to prioritize the ABCs (Airway, Breathing, Circulation) in any trauma situation.
