You have a new patient!
A 48-year-old man was brought to the ED by ambulance shortly after sustaining blunt trauma to the face. The patient was off-loading his quad bike from a truck when it accidentally flipped over and fell directly on his face. He could not recall the incident.
Upon arrival, his vitals were BP: 144/85 mmHg, HR: 104 bpm, T: 36.8°C, RR: 23 bpm, and SPO2: 99% on room air. He was awake on the AVPU score. On examination, the patient was bleeding profusely from his nostrils, breathing from his mouth, and having diffuse facial swelling. You are concerned about the extent of the injuries sustained, and you assemble a team to manage the patient.
Importance
The significance of proficiently managing maxillofacial trauma in the fast-paced emergency medicine setting cannot be overstated. Not only do these traumas cause direct physical harm, but they also impact the patient’s appearance and their ability to perform vital functions like breathing, speaking, and chewing. Given the complex and sensitive nature of the maxillofacial region, emergency physicians must comprehensively understand how to manage such injuries effectively. Proficiency in diagnosing and managing maxillofacial trauma ensures timely and appropriate treatment and prevents potential complications and long-term sequelae.
Epidemiology
Maxillofacial injuries are a prevalent global health concern. There were an estimated 7.5 million new facial fractures globally in 2017, with 1.8 million individuals living with a disability from a facial fracture [1]. Undoubtedly, the incidence and prevalence vary significantly from one country to another. Singaram et al. reported that the prevalence varied between countries from 17% to 69% [2]. In many regions, inadequate infrastructure, limited access to healthcare, and poor safety regulations contribute to a higher incidence of maxillofacial injuries.
Pathophysiology
Road traffic accidents, interpersonal violence, industrial accidents, and sports-related incidents are the most common etiologies of maxillofacial injuries globally. However, the predominant causes differ in developed and developing countries. Assault is the most common mechanism of injury in developed countries, while motor vehicle accident (MVA) is the most common mechanism in developing countries [3].
Low or high-impact forces can cause maxillofacial injuries. The force needed to cause damage differs from one bone to another. For instance, the zygoma and nasal bones can be damaged by low-impact forces. In contrast, the frontal bone, supraorbital rim, maxilla, and mandible are damaged by high-impact forces [4].
Furthermore, the etiology of maxillofacial trauma can predict the type of facial injuries and fractures sustained. For example, MVAs have been associated with higher instances of mandibular fractures. That is mainly due to its position compared to the rest of the facial bones and its relatively thin structure [5].
Medical History
Maxillofacial injuries often occur in association with other injuries and, thus, can be missed initially. Obtaining a systemic and thorough history can aid the diagnosis. At the initial presentation, the mnemonic “AMPLE” (Allergies, Medications currently used, Past illness/Pregnancy, Last meal, Events/Environment related to the injury) can be used to assess the patient’s pre-injury health status. Then, the following should be probed:
What was the mechanism of injury?
Understanding the cause of the injury (e.g., fall, vehicle collision, assault) provides insights into potential injuries and the extent of trauma. Different mechanisms (blunt vs. penetrating, low vs. high-impact) influence the pattern and severity of injuries and aid in anticipating associated injuries.Environment related to the injury
Environmental context (e.g., construction site, sports field) can highlight additional risk factors or clues about the nature and potential complications of the injury. It may also help assess the likelihood of secondary injuries or infections.Blunt vs. penetrative
The type of trauma affects the damage pattern. Blunt trauma may result in fractures or soft tissue injuries, while penetrating trauma may involve more focal injury with a higher risk of infection and internal damage.Low vs. high-impact force
High-impact injuries are more likely to cause fractures and significant soft tissue damage. Knowing the force helps anticipate the severity and depth of injuries.Direction of force
The direction can indicate which structures might be compromised (e.g., anterior force could affect the nose, mandible, and dental structures, while lateral force may impact the zygomatic arch or TMJ).
Was there a loss of consciousness or an altered level of consciousness?
Altered consciousness or loss of consciousness may indicate a head injury or neurological involvement, which necessitates further investigation and monitoring for brain injury.Are there any visual disturbances?
Vision changes can signal orbital fractures or injuries to the optic nerve, potentially affecting ocular function or indicating damage to the orbit and nearby structures.Is there any change in hearing? Is the patient experiencing tinnitus or vertigo? Did they notice any discharge from the ears (clear or bloody)?
Hearing changes, tinnitus, vertigo, or ear discharge suggest possible basilar skull fractures or damage to the auditory system, which are essential to identify to avoid long-term complications.Any trouble breathing through the nose? Did they notice any discharge (clear or bloody)?
Difficulty breathing through the nose or nasal discharge may indicate nasal fractures, airway obstruction, or cerebrospinal fluid (CSF) leakage if clear, which is critical to address in traumatic injuries.Any pain while talking? Do the teeth come together normally?
Pain when speaking or abnormal occlusion may signal fractures in the mandible, maxilla, or TMJ dislocation, impacting facial symmetry, function, and long-term outcomes.Is there difficulty opening or closing the mouth? Is there any pain when biting down the teeth?
Difficulty or pain in mouth movement often suggests mandibular fractures or TMJ injury. Restricted movement can help identify specific injury locations and aid in planning management.Numbness or tingling sensation in any area of the face?
Sensory changes suggest possible nerve damage, often related to fractures affecting the infraorbital, mental, or other facial nerves. This information helps predict potential complications and guides treatment planning.
Consider the following symptoms when obtaining a history from maxillofacial trauma patients:
- Orbital floor fractures commonly present with symptoms such as tingling or numbness around the nose, upper lip, and maxillary gums due to infraorbital nerve damage, along with difficulty looking upward or laterally, double vision (diplopia), and pain during eye movement.
- Nasal fractures are characterized by swelling, pain, and nosebleeds (epistaxis).
- Nasoethmoidal fractures can cause cerebrospinal fluid (CSF) rhinorrhea, epistaxis, and tearing (epiphora) due to nasolacrimal duct obstruction.
- Zygomaticomaxillary complex (ZMC) fractures may lead to numbness around the nose and upper lip, issues with eye movement, double vision, and difficulty opening the mouth (trismus).
- Maxillary fractures often result in CSF rhinorrhea or epistaxis and may cause mobility in the upper teeth and gingiva.
- Alveolar fractures are typically associated with gingival bleeding.
- Mandibular fractures can present as painful jaw movements and tingling or numbness affecting half of the lower lip, chin, teeth, and gingiva.
Red Flags in History
Due to the complex nature of the maxillofacial region, one should be vigilant for red flags when taking history from the patients. Its proximity to the brain and central nervous system makes injuries to these very likely. Thus, identifying them early on can prevent irreversible sequelae and medicolegal implications. Red flags include memory loss, fluctuations in the level of consciousness, nausea/vomiting, and headache that does not improve with analgesia [6].
Neurological involvement can further be assessed by asking about the presence of diplopia or a change in visual acuity. Vision loss usually occurs immediately, but in 10%, symptoms are delayed [7]. Another red flag that is associated with high morbidity and mortality is cervical cord syndrome. Maxillofacial injuries associated with falls are often associated with cervical spinal injury. The patient may complain initially about neck pain or a loss of motor/sensory function in the arms [8].
Physical Examination
Maxillofacial trauma is commonly associated with polytrauma [9]. Thus, it often gets missed in examinations. Physical examination should be done systematically to ensure that all injuries are noted. Like all trauma cases, life-threatening injuries should be addressed first, and the ATLS protocol should be applied accordingly. After that, a physical examination of maxillofacial trauma would involve several key steps. Hard and soft tissue injuries (hematoma, laceration, foreign body, swelling, missing tissue, bleeding, or clear discharge) should be noted upon general inspection of the head and face. Symmetry and alignment of the face should also be noted, bearing in mind that asymmetry may be hidden by edema [10]. Facial elongation and flattening can be seen in midface fractures. Increased intercanthal distance, also known as telecanthus, indicates a nasoethmoidal injury.
Palpation of the whole face should follow, going from top to bottom to avoid missing any injury. Identify step-offs, crepitus, instability or excessive mobility, and malocclusion. Le Fort fractures, complex midface fractures, can be identified during physical examination.
Next, a complete ocular examination should be done. Assess visual acuity, visual field, pupillary reflex, anterior chamber, and extraocular movements. An ophthalmologic consultation is recommended if any abnormalities are present [10]. The nose and septum should be inspected for any hematoma, bulging mass, or CSF leakage and palpated for any signs of fracture. The oral cavity should be inspected for palatal ecchymoses, lacerations, malocclusion, or missing teeth. Manipulate each tooth individually for movement or pain. Palpate the entire mandible for step-offs or injury. Motor and sensory functions of the face should be evaluated. A thorough cranial nerve examination will help identify sensorimotor injuries.
Le Fort Classification
Le Fort I Fracture: A Le Fort I fracture, often referred to as a “floating palate,” is a horizontal maxillary fracture that separates the teeth from the upper face. The fracture line passes through the alveolar ridge, lateral nose, and the inferior wall of the maxillary sinus. Patients with this fracture often present with a swollen upper lip, open bite malocclusion, and ecchymosis of the hard palate. When the forehead is stabilized, the maxilla may also have noticeable mobility (including the hard palate and teeth).
Le Fort II Fracture: Known as a “floating maxilla,” the Le Fort II fracture builds upon the characteristics of Le Fort I but extends to involve the bony nasal skeleton, giving it a pyramidal shape. This fracture often leads to a widening of the intercanthal space, bilateral raccoon eyes, epistaxis, and open bite malocclusion. Physical examination may reveal mobility of the maxilla and nose, ecchymosis of the hard palate, and cerebrospinal fluid (CSF) rhinorrhea. Patients may also experience sensory deficits in the infraorbital region extending to the upper lip.
Le Fort III Fracture: Referred to as a “floating face” or “craniofacial disjunction,” the Le Fort III fracture involves a separation of the midfacial skeleton from the base of the skull. The fracture line extends from the frontozygomatic suture across the orbit and through the base of the nose and ethmoid region, running parallel with the skull base. Physical signs include bilateral raccoon eyes, ecchymosis of the hard palate, and a dish-face deformity characterized by elongation and flattening of the face. Additional signs may include enophthalmos (sunken eyes), Battle’s sign (ecchymosis over the mastoid bone), CSF rhinorrhea or otorrhea, and hemotympanum.
Red Flags in Examination
Look for “red flags” during physical examination. These red flags include cervical spine injuries, loss of teeth, Battle’s sign/Raccoon eyes with CSF rhinorrhea, and Le Fort fractures. Facial bones should not be manipulated until cervical spine injuries, which are present in 2.2% of cases, have been ruled out [11]. The oral cavity should be carefully examined for loss of teeth, as it may be aspirated during the injury. For missing teeth, a chest X-ray should be done to rule out or confirm aspiration.
Moreover, facial fractures can extend to the cranium [4]. Depending on the mechanism of injury, the patient may suffer from a concomitant base of the skull fracture, which may present with Battle’s sign and Raccoon eyes as well as CSF rhinorrhea in some cases [11]. LeFort fractures are complex fractures of the midface and are further classified into LeFort I, II, and III. These fractures are considered a red flag as they may cause airway obstruction and life-threatening bleeding [12].
Alternative Diagnoses
Given that the cause is usually known, doctors must identify the injuries sustained and the extent of injuries sustained. While blunt trauma to the face is an apparent cause of maxillofacial injuries, concomitant and alternative diagnoses should not be missed. Patients with maxillofacial trauma can present with a wide range of symptoms that are similar to those from intracranial and cervical spinal injuries.
Acing Diagnostic Testing
The diagnosis of maxillofacial injuries is not based on a single diagnostic test. It is a correlation between history, physical examination, and imaging studies. Given that the etiologies of the injury vary, the differentials are vast, and the clinical presentation differs from one patient to another. Thus, bedside testing and laboratory studies should be tailored to each patient’s clinical presentation and existing symptoms.
Bedside Testing
ECG monitoring is essential for all trauma patients. Dysrhythmias, atrial fibrillation, and ST segment changes can be seen in blunt cardiac injury. Point-of-care (POCT) glucose testing quickly assesses the patient’s glucose level. Hypoglycemia can cause confusion and an altered mental status, which are common findings in patients with maxillofacial trauma. Point-of-care blood gas testing may be beneficial in case of excessive bleeding or airway compromise. In case of tissue hypoperfusion and shock, metabolic acidosis and elevated lactate levels may be noted. Oxygen saturation and carbon dioxide should be monitored in case of midface fractures and suspected airway compromise. A POCT pregnancy test should be done in women of childbearing age, as almost all maxillofacial trauma patients require imaging for diagnosis.
Laboratory Testing
A complete blood count (CBC), particularly hemoglobin and hematocrit, is indicated when the patient is bleeding profusely. LeFort II and III have been associated with an increased risk of life-threatening hemorrhage compared to other facial fractures [12]. Therefore, blood typing and crossmatching are crucial if the patient needs a blood transfusion. A coagulation panel is done to rule out trauma-induced coagulopathy, a preventable factor for progressive brain injury and massive bleeding [13].
A CSF analysis is warranted when there are secretions from the nose or ear. Beta-2 transferrin testing is the current preferred test to confirm the presence of a CSF leak [14]. Other less used methods include beta-trace protein, double-ring sign, and glucose oxidase test. A blood ethanol test and urine toxicology screen can be considered in agitated patients or those with altered levels of consciousness.
Imaging Studies
CT scans are the “gold standard” diagnostic modality for evaluating maxillofacial trauma [15]. Using narrow-cut CT scans without contrast provides detailed cross-sectional images of the facial structures, thus allowing for a comprehensive evaluation of complex fractures. In addition to identifying facial fractures, it can detect head and cervical spinal injuries, air and fluid in the intracranial space and sinuses, periorbital injury, soft tissue injury, and embedded foreign bodies. A non-contrast head CT helps identify intracranial bleeding and distinguish between the types of bleeds if present. This is recommended, especially when the patient experiences loss of consciousness for several minutes. Because maxillofacial trauma is highly associated with cervical spine injury, the physician must have a high index of suspicion for cervical spine fractures. The NEXUS criteria is used to guide imaging in these situations.
Plain radiographs of the head are used when CT scans are not available. They may be used to screen for fractures and provide some insight into displaced fragments, but they have low sensitivity for detecting and establishing the extent of the injuries. A chest x-ray should be done when a missing tooth is noted on physical examination, as the patient may have aspirated it.
Ultrasound is a helpful bedside diagnostic tool in any trauma patient, and it has been shown to be an accurate diagnostic method when evaluating orbital trauma [16]. It is used when an isolated orbital injury is suspected or a CT scan is not readily available. It can pick up muscle entrapment, soft-tissue herniation, and orbital emphysema.
Risk Stratification
Several risk stratification tools have been developed for maxillofacial trauma. However, these are commonly used in clinical research to assess injury severity and determine the appropriate course of action. Although no specific tool was developed for use in an emergency department, other nonspecific tools like the Glasgow Coma Scale (GCS) and NEXUS criteria come in handy. The GCS score is used to rapidly assess the patient’s level of consciousness, guiding immediate interventions. The NEXUS criteria is used to clear patients from cervical injury clinically without imaging.
The diagnosis of maxillofacial trauma is based on a combination of clinical assessment and diagnostic imaging. A thorough evaluation of both helps predict the risk. Some common clinical factors that may contribute to poorer outcomes include severe and complex fractures, extensive soft tissue injury, high-energy trauma, open fractures, ocular injuries, and pediatric and geriatric age groups [17,18].
Management
Initial Stabilization
Treating patients with maxillofacial trauma aims to restore function and optimize appearance. However, the primary focus upon presentation is to stabilize the patient. Initial management begins with a primary survey, which constitutes the “ABCDE” approach to identify life-threatening conditions and treat them promptly.
Airway
Airway patency is a serious concern in maxillofacial trauma, and the nature of the injury often complicates airway management. Airway compromise may be complete, partial, or progressive [9]. Early signs of airway compromise include tachypnea, inability to speak in complete sentences, and abnormal noisy breathing. Agitation and abnormal behavior may indicate hypercapnia.
If the patient has obstruction from soft tissue, perform a jaw thrust maneuver. Cervical spine injury should be presumed in all maxillofacial injury patients until proven otherwise. Therefore, avoid mobilizing the neck until it is cleared. Inspect the oral cavity for any bleeding or secretions and suction accordingly. Consider manual removal with a finger sweep or forceps if a foreign body or debris is identified. Control patients with nasopharynx or oropharynx bleeding with nasal packing or compression with gauze [19].
The need for airway protection increases with severe maxillofacial fractures, expanding neck hematoma, stridor, profuse bleeding or continuous vomiting, and unconsciousness [9]. A nasopharyngeal airway is indicated in a conscious patient without a midface trauma. If the patient was unconscious or had a midface injury, an oropharyngeal airway may help temporarily. However, a definitive airway must be secured in patients who cannot maintain airway integrity. Definitive airway control is done by an endotracheal intubation (nasal or oral). Nasal endotracheal intubation is contraindicated in a base of skull fracture. Given the area’s delicacy and complexity of the injuries sustained, fiberoptic intubation by a skilled physician may provide immediate confirmation of tracheal placement and avoid further complications [10]. If the previous methods cannot be accomplished, a surgical airway (cricothyroidotomy or tracheostomy) should be considered.
Breathing
The patient’s breathing, ventilation, and oxygenation should be assessed. Check the alignment of the trachea and listen to the patient’s chest bilateral for air entry and added sounds. Deviated trachea and decreased air entry upon auscultation increase the likelihood of tension pneumothorax, and a needle decompression should be performed. Look for soft tissue abnormalities and subcutaneous emphysema.
The patient should be connected to a pulse oximeter to monitor adequate hemoglobin oxygen saturation. If the patient is hypoxic, they should receive oxygen supplementation. Non-invasive ventilation should precede invasive ventilation methods. However, in severe injuries, mask ventilation may be difficult due to the disrupted anatomy of the face [20].
Like all trauma patients, a “full stomach” should be presumed in patients with maxillofacial trauma as digestion stops during trauma. In addition, blood is often swallowed and accumulates in the stomach. Regurgitation and aspiration are a big risk in such patients, and evacuation of stomach content is recommended [20]. A nasogastric tube is contraindicated in a skull base fracture. An orogastric tube is recommended instead to prevent intracranial passage [21].
Circulation
Maxillofacial trauma can cause profuse bleeding that can lead to shock. Monitor blood pressure and heart rate, auscultate, and check capillary refill and hand warmth. Tachycardia precedes low blood pressure in shock. Establish bilateral IV access with two large bore cannulas and draw blood for type and crossmatch. Fluid therapy with crystalloids should be initiated. Identify the source of hemorrhage. If external or intraoral bleeding occurs, apply direct pressure, pack, and suture. Carefully examine the tongue, as persistent bleeding can obscure the airway. In the case of epistaxis, anteroposterior packing will control the bleeding in most cases [10]. Additionally, topical tranexamic acid can be used in anterior epistaxis. In cases of LeFort fractures, intermaxillary fixation might be required when packing fails to stop the bleeding [10]. If the previously mentioned measures fail, consult IR, ENT, or surgery for more advanced interventions like arterial embolization and fracture reduction [22].
Disability
The patient’s mental status and neurologic function should be assessed initially. Glucose is measured at this point if not done upon arrival. The Glasgow Coma Scale helps assess the patient’s level of consciousness. Note any change in the mental status. A brief neurological exam is recommended.
Exposure
Expose the patient fully while keeping them warm. Look for bruises, bite marks, lacerations, and other injuries, as the etiology of maxillofacial trauma is broad and often presents as polytrauma. Decontamination might be required depending on the nature of the trauma.
Medications
Isotonic crystalloid fluids and blood products are common treatments in trauma patients. Adequate pain management should be provided with NSAIDs, opioids, or local anesthesia. There are no guidelines on the use of prophylactic antibiotics in maxillofacial trauma. Nonetheless, there are specific scenarios where prophylactic antibiotics administration is recommended. Depending on the type of injury sustained, additional medications might be required. Refer to Table to explore the additional medications used in the setting of maxillofacial trauma:
Drug name (Generic) | Potential Use | Dose | Frequency | Cautions / Comments |
Acetaminophen | mild-moderate pain (can be given with NSAIDs, with or without Opioids) | 325-1,000 mg PO
Max Dose: 4 g daily | q4-6h |
|
Ibuprofen | mild-moderate pain (can be given with Acetaminophen) | 600 mg PO
Max Dose: 3,200 mg daily | q6h |
|
Hydromorphone | Moderate – severe pain | 0.5-4 mg IV/IM/SC
Max Dose: n/a | q4-6h |
|
Morphine sulfate | Moderate – severe pain | 2.5-10 mg IV/IM/SC
Max Dose: n/a | q2-6h |
|
Metoclopramide | Nausea and vomiting (to prevent risk of aspiration) | 1 to 2 mg/kg/dose IV
Max Dose: n/a | Every 2 hours for the first two doses, then every 3 hours for the subsequent doses. |
|
Ondansetron | Nausea and vomiting (to prevent risk of aspiration) | 0.15 mg/kg IV (not to exceed 16 mg)
Max Dose: n/a | q8hr PRN |
|
Amoxicillin-clavulanic acid | Nasal packing (ppx for epistaxis – TSS)
Facial fractures communicating with open wounds of the skin
Mandibular fractures that extend into the oral cavity | 2g PO (extended-release tablets)
Max Dose: n/a | q12h (7 days) |
|
Procedures
Epistaxis: Epistaxis is a common issue in maxillofacial trauma due to damage to the nasal structures and blood vessels. Managing epistaxis is crucial to prevent blood loss and ensure the airway remains clear. For anterior epistaxis, anterior nasal packing can effectively apply pressure to stop the bleeding. If the bleeding source is posterior, posterior nasal packing using a balloon catheter or Foley’s catheter may be necessary. These techniques help control bleeding and stabilize the patient, especially in cases where blood loss might obstruct the airway or lead to hemodynamic instability.
Inability to Protect Airway: In cases of severe maxillofacial trauma, there may be a risk of airway compromise due to swelling, bleeding, or physical obstruction from broken facial structures. If a patient cannot protect their airway, endotracheal intubation is required to secure it and maintain ventilation. Intubation provides a definitive airway, bypassing obstructions and ensuring adequate oxygenation, which is critical in trauma patients to prevent hypoxia and support life-sustaining measures.
Failed Intubation: Occasionally, intubation may be unsuccessful, particularly in patients with extensive facial injuries or anatomical challenges. In such cases, a cricothyroidotomy is performed. This emergency surgical procedure creates an opening in the cricothyroid membrane, providing an alternative airway route directly into the trachea. Cricothyroidotomy is a life-saving measure when intubation fails, ensuring oxygen can still be delivered to the lungs when other methods are ineffective.
Tension Pneumothorax: Maxillofacial trauma can sometimes be associated with thoracic injuries, leading to complications like tension pneumothorax, where air is trapped in the pleural cavity and compresses the lungs and heart, causing a life-threatening situation. Needle decompression is the first step in relieving the pressure by inserting a needle into the pleural space to allow trapped air to escape. This is followed by a tube thoracostomy (chest tube placement) to maintain the release of air and prevent the recurrence of tension pneumothorax. This procedure is essential to restore normal lung function and stabilize the patient’s respiratory status.
Special Patient Groups
Pediatrics
Pediatric patients’ anatomical and developmental differences should be considered when evaluating them for maxillofacial trauma. An infant’s frontal bone dents, while a child’s frontal bone experiences a depressed fracture under a force that causes facial fractures in adults [4]. Smaller force loads are needed to damage the facial bones than adults [4]. Given pediatric patients’ underdeveloped facial skeletons and sinuses, growth dysplasia is a common outcome of suboptimal treatment. Standard facial radiographs often miss fractures; a CT scan is more reliable in this age group [23]. Assess for orbital fracture thoroughly, as children’s orbital floor is pliable, increasing the risk of entrapment and rectus muscle ischemia [6].
Geriatrics
The impaired physiologic response and frailty of geriatric patients make their treatment more challenging. Although they are subject to the same mechanism of maxillofacial trauma as the other age groups, their response to the injuries differ. They are at a high risk of intracranial hemorrhage, but their basal vital signs often do not reflect signs of hemorrhage or hypoperfusion, making diagnosing shock difficult. Comorbidities and polypharmacy in this age group further mask the normal shock response. In addition, the likelihood of associated injuries in this group is high [24]. Elderly patients were reported to have more frequent cerebral concussions and internal organ injuries [25]. Nonetheless, a GCS of <15 has also been associated with higher mortality rates, especially in those older than 70 years [25]. Putting all of this into perspective when assessing elderly patients, a lower threshold for extensive investigations and referral is necessary.
When to admit this patient
Definitive repair of facial fractures is not a surgical emergency, and patients can be discharged home with a close follow-up in the clinic in most cases. An awake patient with good home care and isolated stable injuries (i.e., mandibular or nasal fracture) may be discharged home. However, admission should be considered in a number of situations. These include severe complex facial fractures, open fractures, the presence of comorbidities, and cases of associated injuries that need close monitoring. Admission is made to the intensive care unit or a surgical ward with a high level of monitoring.
Revisiting Your Patient
A 48-year-old male was brought to the ED by ambulance shortly after sustaining blunt trauma to the face. The patient was loading his quad bike off a truck when it accidentally flipped over and fell directly on his face and upper body. He could not recall what happened thereafter.
Upon arrival, his vitals were BP: 144/85 mmHg, HR: 104 bpm, T: 36.8°C, RR: 23 bpm, and SPO2: 99% on room air. He was awake on the AVPU score. On examination, the patient was bleeding profusely from his nose, breathing from his mouth, and having diffuse facial swelling. You are concerned about the extent of injuries sustained and have assembled your team to manage the patient adequately.
History was taken from his brother, who witnessed the incident. The brother confirmed that the patient had no LOC, dizziness, or vomiting but reported that the patient kept complaining of neck pain. He is known to have L5-S1 disc prolapse, does not take any medication, and has no known allergies.
You worry that the patient might suffer from airway compromise and quickly begin your primary survey. You hear gurgling noises and check the patient’s mouth to find it filled with blood. You suction and look for sources of bleeding in the mouth but find none. The airway becomes patent. You notice that EMS has placed a C-spine collar on the patient already. His lungs are clear bilaterally, and you insert an orogastric tube to suction his stomach contents. He is bleeding profusely from his nostrils, so you pack his nose anteriorly. This does not stop the bleeding, and the patient is spitting out blood. You then apply topical tranexamic acid and more packs, and the bleeding stops. His pulses are present, extremities are warm, and capillary refill time is less than 2 seconds. His GCS is 15/15, and his pupils are reactive to light. Upon exposing him, you notice lacerations on his lips and ears but no other injuries on the rest of his body.
Two large bore IV lines are inserted peripherally, blood is drawn for laboratory investigations, and intravenous normal saline is administered immediately. A 12-lead ECG demonstrated sinus tachycardia. You perform a bedside E-FAST to rule out pneumothorax/hemothorax, pericardial fluid, and peritoneal fluid. You ask for urgent CT scans, including a CT Head and Neck without contrast and a Maxillofacial CT. The CT scan report confirms no C-spine fractures, skull fractures, or brain injury. However, it identifies a Le Fort 1 fracture and fracture involving the right orbital wall. You safely remove the c-spine collar. You consult the Oral and Maxillofacial surgeon and the Ophthalmologist, and both agree to see the patient. You give the patient morphine to alleviate his pain.
You performed a secondary survey to ensure the patient was not deteriorating and to identify any additional injuries. The patient remained stable, and he was admitted to the surgical floor.
Author
Maitha Ahmad Kazim
Dr. Maitha Ahmad Kazim is an Emergency Medicine Resident at Dubai Health, recognized for her dedication in patient care and medical research. She earned her Doctor of Medicine degree from the United Arab Emirates University, where she graduated with distinction. Dr. Kazim is known for her commitment to advancing emergency care, demonstrated by her active engagement in research, mentorship, and medical education.
David O. Alao
David is a senior consultant in emergency medicine and associate professor of medicine College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
He graduated from the University of Ibadan, Nigeria. After initial training in general surgery in Leeds and Newcastle Upon-Tyne, United Kingdom, he had higher specialist training in emergency medicine in the South West of England.
He was a consultant in emergency medicine for 15 years at the University Hospitals Plymouth, United Kingdom where he was a Clinical Tutor, Academic Tutor and, Assistant professor at Plymouth University Peninsular School of Medicine and Dentistry (PUPSMD) UK.
David is a fellow of the Royal College of Surgeons of Edinburgh and the Royal College of Emergency Medicine UK.
His interests are undergraduate and postgraduate medical education, skills training and transfer, trauma systems development and resuscitation science. He has published over 30 papers in peer-reviewed journal.
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Reviewed By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
