The ABCDE Approach to Undifferentiated Critically Ill and Injured Patient (2024)

November 11, 2024November 11, 2024 ~ iEM Education Project Team ~ Leave a comment

by Roxanne R. Maria, Hamid A. Chatha

You have a new patient!

A 40-year-old male, a truck driver, is involved in a head-on collision with another vehicle. He has been brought in by ambulance. According to the paramedics, the vehicles were traveling at approximately 85 km/hr, and the patient was restrained by a seatbelt. On arrival at the Emergency Department (ED), the patient is agitated and mildly disoriented. He is tachypneic with a respiratory rate of 30/min, maintaining an O2 saturation of 95% on 12 L/min oxygen via a non-rebreather mask, heart rate of 128 beats/min, blood pressure of 90/52 mmHg, and temperature of 36.1°C. The patient also received 1 L of 0.9% normal saline and 1 unit of O-negative packed red cells in the ambulance. Despite this, his respiratory rate, heart rate, and level of disorientation have worsened.

Emergency Department

In the ED, patients present with a variety of clinical presentations, including both life-threatening and non-life-threatening. Some may have been seen and referred by a clinician before arrival or brought to the department after pre-hospital assessment and care by the emergency medical services (EMS) [1]. Health emergencies affect all age groups and include conditions like acute coronary syndrome, strokes, acute complications of pregnancy, or any chronic illness. Emergency health care providers should respond to these clinically ‘undifferentiated’ patients with symptoms for which the diagnosis may not be known [2]. The root cause of most life-threatening conditions in the ED may be medical or surgical, infection or trauma [2].

In the Emergency Department (ED), there are several potentially life-threatening presentations that demand immediate stabilization. These include trauma, which can result from various forms of accidents or injuries, and shortness of breath, which might indicate critical respiratory distress. An altered mental state also requires prompt attention, as it may signal underlying neurological or systemic issues. Shock, often evidenced by dangerously low blood pressure. Chest pain or discomfort, which could be indicative of a cardiac event, are other urgent concerns. Additionally, cases of poisoning, ingestion of harmful substances, or exposure to toxic materials also necessitate rapid intervention to prevent further harm. Each of these presentations is a medical priority, highlighting the importance of timely and effective response in the ED to ensure patient safety and stability.

These symptoms maybe the only picture that the patients present with, and may constitute the early stage of a critical illness requiring rapid, appropriate intervention and resuscitation, even when the patient seems to appear relatively well [2].

Emergency conditions often require immediate intervention long before a definitive diagnosis is made to stabilize the critically ill patient [3]. Thus, this chapter intends to briefly introduce a basic systematic approach to identifying and managing acute, potentially life-threatening conditions in these patients. This approach will enable all frontline providers, including students, nurses, pre-hospital technicians, and physicians, to manage these patients even in the setting of limited resources [2].

A complete assessment and management of each of the presentations mentioned above is beyond the scope of this chapter. However, the initial approach remains the same, regardless of the patient population or setting [4].

History of the ABCDE approach

The ABC mnemonic’s origins may be traced back to the 1950s. The first two letters of the mnemonic, A and B, resulted from Dr Safar’s description of airway protection techniques and administration of rescue breaths. Kouwenhoven and colleagues later added the letter C to their description of closed-chest cardiac massage [3].

Styner is credited with further developing the Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) approach. After a local aircraft disaster in 1976, Styner and his family were taken to a local healthcare facility, where he saw an insufficiency in the emergency treatment offered. He then founded the Advanced Trauma Life Support course, emphasizing a methodical approach to treating severely injured patients.

The ABCDE approach is universally accepted and utilized by emergency medicine clinicians, technicians, critical care specialists, and traumatologists [3]. Thus, this approach is recommended by international guidelines for suspected serious illness or underlying injury, irrespective of the diagnosis [5]. It is also the first step in post-resuscitation care after the patient achieves return of spontaneous circulation (ROSC) from a cardiac arrest [3]. This systematic approach also aims to improve coordination among the team members and saves time to make critical decisions [3].

The ABCDE approach

Since time is of the essence, the ABCDE method is a systematic approach that can be easily and quickly practiced in the ED. This is incorporated into what is known as ‘Initial patient assessment,’ one of the most crucial steps in evaluation [6]. At each step of this approach, life-threatening problems must be addressed before proceeding to the next assessment step. After the initial assessment, patients must be reassessed regularly to evaluate the treatment response. Anticipate and call for extra help early [7]. Appropriate role allocation and good communication are important for effective team working [7]. Once the patient is stabilized, a secondary survey should be conducted, which includes a thorough history, physical examination, and diagnostic testing [8]. Finally, the tertiary survey is done within 24 hours of presentation to identify any other missed injuries in trauma. Once it is recognized that the patient’s needs exceed the facility’s capabilities, the transfer process must be initiated to an appropriately specialized care center accordingly [8].

Ensure Safe Environment

Before initiating the ABCDE approach, it is essential to ensure both personal safety and a secure environment. This preparation includes addressing any potential risks, such as unexpected or violent behavior, environmental hazards, and the risk of exposure to communicable diseases. Health professionals should consider using appropriate personal protective equipment (PPE) suited to the situation, which may include gloves, gowns, masks, goggles, and thorough hand washing. These precautions are vital to protect both the healthcare provider and the patient, ensuring a safe environment for medical intervention [4].

Initiate First Response

The Resuscitation Council UK (RCUK) (2015) recommends performing a range of initial activities before proceeding with the ABCDE approach [4].

Examine the patient in general (skin color, posture, sensorium, etc.) to determine whether they seem critically ill [4].

After introducing yourself, an initial assessment can be completed in the first 10-15 seconds by asking patients their names and about their active complaints. If they respond normally, it means the airway is patent and brain perfusion is expected [9]. Check for breathing and pulse if the patient appears unconscious or has collapsed. If there is no pulse, call for help and immediately start cardiopulmonary resuscitation (CPR), adhering to local guidelines [9].

Detailed ABCDE Evaluation

Primary Survey

Patients are assessed and prioritized according to their presentations and vital signs. In primary survey, critically ill patients are managed efficiently along with resuscitation. The approach represents the sequence of steps as described below [10]:

A – Airway (with C spine control in Trauma patients)

B – Breathing and Ventilation

C – Circulation (With Hemorrhage control in active bleeding)

D – Disability

E – Exposure / Environment control

A – Airway

Airway obstruction is critical! Gain expert help immediately. If not treated, it can lead to hypoxia, causing damage to the brain, kidneys, and heart, resulting in cardiac arrest and death [4].

Airway management remains the cornerstone of resuscitation and is a specialized skill for the emergency clinician [9].

Assessment of airway patency is the first step. Can the patient talk? If yes, then the airway is patent and not in immediate danger. If not, look for the signs of airway compromise: Noisy breathing, inability to speak, presence of added sounds, stridor or wheezing, choking or gagging, cyanosis, and use of accessory muscles.

The next step is to open the mouth and look for anything obstructing the airway, such as secretions, blood, a foreign body, or mandibular/tracheal/laryngeal fractures [10].

While examining and managing the airway, great care must be taken to restrict excessive movement of the cervical spine and assume the existence of a spinal injury in cases of trauma [11].

Several critical factors can compromise a patient’s airway and must be addressed promptly in emergency settings. A depressed level of consciousness, which may result from conditions such as opioid overdose, head injury, or stroke, can impair airway protection and lead to significant risk [10]. Additionally, an inhaled foreign body, or the presence of blood, vomit, or other secretions, can obstruct the airway and necessitate immediate intervention. Fractures of the facial bones or mandible further complicate airway management due to potential structural damage. Soft tissue swelling, whether caused by anaphylaxis (angioedema) or severe infections like quinsy or necrotizing fasciitis, also seriously threatens the airway. These conditions highlight the importance of vigilant monitoring and rapid response to maintain airway patency and prevent complications.

Intervention: Several basic maneuvers can help maintain a clear airway. Suctioning should be performed if there are any secretions or blood present. Additionally, using the head-tilt, chin-lift, and jaw-thrust maneuvers can aid in keeping the airway open. For patients with a low Glasgow Coma Scale (GCS) score, placing an oropharyngeal or nasopharyngeal airway can be beneficial in maintaining airway patency. It’s also important to inspect the airway for any obvious obstructions; if a visible object is within reach, it may be removed carefully using a finger sweep or suction. It is crucial to remember that assistance from an anesthetist may be required in some cases.

In trauma patients, to protect the C-spine, perform a jaw-thrust rather than a head-tilt chin-lift maneuver and immobilize the C-spine with a cervical collar [9].

A definitive airway, such as endotracheal intubation, may be necessary in patients with airway obstruction, GCS ≤ 8, severe shock or cardiac arrest, and at risk of inhalation injuries [8].

If intubation has failed or is contraindicated, a definitive airway must be established surgically [11].

B – Breathing and Ventilation

Effective ventilation relies on the proper functioning of the lungs, chest wall, and diaphragm, along with a patent airway and sufficient gas exchange to optimize oxygenation [10]. To assess breathing and ventilation, clinicians should evaluate oxygen saturation, monitor the respiratory rate for any signs of abnormality—such as rapid breathing (tachypnea), slow breathing (bradypnea), or shallow breathing (Kussmaul breathing)—and observe for increased work of breathing, such as accessory muscle use, chest retractions, or nasal flaring. Other critical assessments include checking for neck vein distention, examining the position of the trachea, chest expansion, and any injuries or tenderness, as well as auscultating for bilateral air entry and any additional sounds. Chest percussion should be performed to identify dullness, which may indicate hemothorax or effusion, or hyperresonance, suggestive of pneumothorax. Certain pathologies, like tension pneumothorax, massive hemothorax, open pneumothorax, and tracheal or bronchial injuries, can rapidly disrupt ventilation. Other conditions, including simple pneumothorax, pleural effusion, simple hemothorax, rib fractures, flail chest, and pulmonary contusion, may compromise ventilation to a lesser degree [10].

Interventions:

Oxygen – Ensure all patients are adequately oxygenated, with supplemental oxygen delivered to all severely injured trauma patients [11]. Place them on well-fitted oxygen reservoir masks with a flow rate > 10 L/min, which can then be titrated as needed to maintain adequate saturations. Other means of oxygen delivery (nasal catheter, nasal cannula, non-rebreather) can also be used.
Bag mask valve ventilation with oxygen – should be given to unconscious patients with abnormal breathing patterns (slow or shallow respiration).
Other interventions include salbutamol nebulizers, epinephrine, steroids, needle decompression, chest tube insertion, and the use of noninvasive ventilation and pressure support in different clinical scenarios.

C – Circulation (With Hemorrhage control in active bleeding)

Major circulatory compromise in critically ill patients can result from either blood volume loss or reduced cardiac output. In trauma cases, hypotension is assumed to be due to blood loss until proven otherwise. To assess the hemodynamic status, several key evaluations should be performed. These include checking the level of consciousness, as an altered state may indicate impaired cerebral perfusion, and assessing skin perfusion for signs like pallor, cyanosis, mottling, or flushing. Vital signs such as heart rate and blood pressure should be monitored for abnormalities like tachycardia, bradycardia, hypotension, or hypertension. Auscultation can reveal muffled heart sounds, which may suggest cardiac tamponade or pneumothorax, as well as murmurs or a pericardial friction rub that could indicate pericarditis. Checking the extremities for capillary refill and skin temperature is also essential. Additionally, palpation of the abdomen for tenderness or a pulsatile mass may reveal an abdominal aortic aneurysm, while peripheral edema, such as pedal edema, might indicate heart failure.

Interventions:

Two large-bore IV cannulations must be placed. If this attempt fails, intraosseous access is necessary. Hemorrhagic shock—A definitive control of bleeding along with replacement of intravascular volume is essential. Initial resuscitation should start with warm crystalloids, and blood products should be used. Massive Transfusion Protocol (MTP) should be activated according to local guidelines. In hemorrhagic shock, vasopressors and reversal of anticoagulation (if required) can be considered.
Hemorrhage control: External hemorrhage can be controlled by direct manual pressure over the site of the wound or tourniquet application.
In the case of pelvic or femur fractures, placement of pelvic binders or extremity splints may help to stabilize, although definitive management may be surgical or interventional radiological procedures.
Obstructive shock – Immediate pericardiocentesis for cardiac tamponade, chest tube insertion for tension pneumothorax, and thrombolysis for massive pulmonary embolism.
Distributive shock – intramuscular epinephrine for anaphylactic shock, empiric antibiotics for sepsis, and hydrocortisone for adrenal crisis.
Appropriate antihypertensives in hypertensive emergency.

D – Disability

Evaluate neurological status either with AVPU (Alert, Verbal, Pain and Unresponsive) [5] or GCS (Glasgow Coma Scale).

Evaluate for agitation, head and neck trauma, focal neurological signs (seizure, hemiplegia, etc), lateralizing signs, meningeal signs, signs of raised intracranial pressure, and pupillary examination (size and symmetry). Identify any classic toxidromes (sympathomimetic, cholinergic, anticholinergic, opioid, serotonergic, and sedative-hypnotic toxidromes).

Choose the best response of patient
EYE OPENING
4: Spontaneously
3: To verbal command
2: To pain
1: No response

BEST VERBAL RESPONSE
5: Oriented and converses
4: Disoriented and converses
3: Inappropriate words; cries
2: Incomprehensible sounds
1: No response

BEST MOTOR RESPONSE
6: Obeys command
5: Localizes pain
4: Flexion withdrawal
3: Flexion abnormal (decorticate)
2: Extension (decerebrate)
1: No response

Glasgow Coma Score (GCS) (Modified from Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness: a practical scale. The Lancet, 304(7872), 81-84.) - Please read this article to get more insight regarding GCS.

The Glasgow Coma Scale (GCS) is a critical tool for assessing the level of consciousness in critically ill patients, providing a score based on eye, verbal, and motor responses. A GCS score ranges from 3 to 15, with lower scores indicating more severe impairment. Scores of 13-15 generally indicate mild impairment, 9-12 suggest moderate impairment, and scores of 8 or below (comatose patient) represent severe impairment and a high risk of poor outcomes. In critically ill patients, a declining GCS score can signal worsening neurological status, potentially due to factors like traumatic brain injury, hypoxia, or systemic deterioration, and often warrants immediate intervention to address underlying causes.

E – Exposure and Environmental control

It is necessary to expose the patient appropriately whilst maintaining dignity and body temperature.

Look at the skin for any signs of trauma (burns, stab wounds, gunshot wounds, etc.), rashes, infected wounds, ulcers, needle track marks, medication patches, implantable devices, tubes, catheters, and stomas; measure core body temperature, and perform logroll (trauma).

Do not forget to check frequently concealed and overlooked areas such as the genital, inguinal, perineal, axilla, back and under dressings [8].

Interventions:

Use specialized personal protective equipment (PPE), remove all possible triggers such as wet or contaminated clothing, and maintain core body temperature.
Minimize hypothermia (external rewarming, warm IV fluids) and hyperthermia (surface cooling, cold IV fluids, antipyretics for fever).

Adjuncts to primary survey

1. Electrocardiography (ECG)
2. Pulse oximetry
3. Carbon dioxide (CO2) monitoring
4. Arterial blood gas (ABG) analysis
5. Urinary catheterization (to assess for hematuria and urine output)
6. Gastric catheterization (for decompression)
7. Blood lactate level measurement
8. Chest and pelvis X-rays
9. Extended focused assessment with sonography for trauma (eFAST)

These adjuncts help provide a comprehensive evaluation of the patient’s condition [10].

Secondary Survey

After the initial primary survey and stabilization, proceed to the secondary survey. This includes a detailed history (SAMPLE)and a head-to-toe examination, including reassessment of vital signs, as there is a potential for missing an injury or other findings in an unresponsive patient [10].

The SAMPLE mnemonic is a structured approach for gathering essential patient history in emergency settings. It stands for Signs and Symptoms, Allergies, Medications, Past Medical History, Last Oral Intake, and Events leading to the illness or injury [5].

“Signs and Symptoms” involves asking the patient, family, or other witnesses about any observable signs or reported symptoms.
“Allergies” are crucial to identify to prevent harm and may help recognize conditions like anaphylaxis.
“Medications” requires a comprehensive list of all current and recent medications, including any changes in dosage.
“Past Medical History” provides insights into underlying health conditions that may influence the current illness.
“Last Oral Intake” is important for assessing risks of aspiration or complications if the patient requires sedation or surgery.
Finally, understanding the “Events” surrounding the illness or injury aids in determining its cause and severity.

Together, these components guide healthcare providers in developing a more accurate and effective treatment plan.

In the secondary survey, a thorough approach is taken to ensure comprehensive care for the patient. This includes performing relevant and appropriate diagnostic tests based on the clinical assessment to confirm diagnoses and guide further treatment. Critical, targeted treatments should be initiated promptly, along with adequate supportive care to stabilize the patient’s condition. If necessary, specialized consults are obtained to address specific medical needs. Additionally, the healthcare team must assess the need for escalation of care or consider an interfacility transfer if the patient requires more specialized resources or advanced care options [8]. This structured approach ensures that all aspects of the patient’s condition are managed effectively.

Adjuncts to secondary survey

Additional x-rays for the spine and extremities, CT scans of the head, chest, abdomen, and spine, urography and angiography with contrast, transesophageal ultrasound, bronchoscopy, and other diagnostics [10].

If the patient starts to deteriorate, immediately go back to the ABCDE approach and reassess!

Special Patient Groups

In recent ATLS updates, the ABCDE approach has been modified to the xABCDEF approach, where “x” stands for eXsanguinating eXternal hemorrhage control and “F” stands for further factors such as special groups (pediatric, Geriatric, and Pregnancy). While the xABCDEF approach is universal and applies to all patient groups, specific anatomic and physiological differences in different populations should be considered while evaluating and treating life-threatening conditions. Some special population groups are discussed here:

Pediatrics [10]

Children have smaller body mass but higher body surface area than their body mass and proportionately larger heads than adults. These characteristics cause children to have increased energy transfer, hypothermia, and blunt brain trauma.

A useful adjunct is the Broselow® Pediatric Emergency Tape, which helps to rapidly identify weight-based medication doses, fluid volumes, and equipment sizes.

The ABCDE approach in children should proceed in the same manner as in adults, bearing in mind the anatomical differences.

Airway – Various anatomical features in children, such as large tissues of the oropharynx (tongue, tonsils), funnel-shaped larynx, more cephalad and anteriorly placed larynx and vocal cords, and shorter length of the trachea, make assessment and management of the airway difficult. Additionally, in smaller children, there is disproportionality in size between the cranium and the midface, making the large occiput in passive flexion of the cervical spine, resulting in the posterior pharynx being displaced anteriorly. The neutral alignment of the spine can be achieved by placing a 1-inch pad below the entire torso of the infant or toddler.

The most preferred technique for orotracheal intubation is under direct vision, along with restriction of the cervical spine, to achieve a definitive airway.

Infants are more prone to bradycardia due to laryngeal stimulation during intubation than older children and adults. Hence, when drug-assisted intubation is required, the administration of atropine sulfate pretreatment must be considered. Atropine also helps to dry out oral secretions, further enhancing the view of landmarks for intubation.

When the airway cannot be maintained by bag-mask ventilation or orotracheal intubation, a rescue airway with either a laryngeal mask airway (LMA), an intubating LMA, or a needle cricothyroidotomy is required.

Red flag signs in children include stridor, excessive drooling, airway swelling, and the child’s unwillingness to move the neck. Examine the airway carefully for any foreign bodies, burns, or obstruction.

Breathing and ventilation – Children’s respiratory rates decrease with age. The normal tidal volumes in infants and children vary from 4-6 ml/kg to 6-8 ml/kg while assisting in ventilation. Care must be taken to limit pressure-related barotrauma during ventilation. It is recommended that children weighing less than 30 kg use a pediatric bag valve mask.

Injuries such as pneumothorax, hemothorax, and hemopneumothorax should be treated by pleural decompression, for tension pneumothorax, and needle decompression in the 2nd intercostal space (over the top of the third rib) at the midclavicular line. The site for chest tube insertion remains the same as in adults.

The most common cause of pediatric cardiac arrest is hypoxia, and the most common acid-base abnormality encountered is respiratory acidosis due to hypoventilation.

Circulation – Important factors in assessing and managing circulation and shock are looking for signs of circulatory compromise, ascertaining the patient’s weight and circulatory volume, gaining timely peripheral venous access, delivering an appropriate volume of fluids with or without blood replacement, evaluating the adequacy of resuscitation, and aiming for thermoregulation.

Children have increased physiological reserves. A 30% decrease in the circulating blood volume may be required for a fall in the systolic blood pressure. Hence, it is important to look for other subtle signs of blood loss, such as progressive weakening of peripheral pulses, narrow pulse pressure to less than 20 mm Hg, skin mottling (in infants and young children), cool extremities, and decreased level of consciousness.

The preferred route is peripheral venous access, but if this is unsuccessful after two attempts, intraosseous access should be obtained.

Fluid resuscitation must be commenced at 20 ml/kg boluses of isotonic crystalloids. If the patient has ongoing bleeding, packed red blood cells may be initiated at 10 ml/kg as soon as possible. Given that children have increased metabolic rates, thinner skin, and lack of substantial subcutaneous tissue, they are prone to develop hypothermia quickly, which may impede a child’s response to treatment, increase coagulation times, and affect the central nervous system (CNS) function. Therefore, overhead lamps, thermal blankets, as well as administration of warm IV fluids, blood products, and inhaled gases may be required during the initial phase of evaluation and resuscitation.

Disability – Hypoglycemia is a very common cause of altered mental state in children, and children can present with altered mental state or seizures. Check for blood glucose in children; if low, administer glucose (IV D10 or D25).

Geriatric [10]

In cases of trauma in geriatric patients, physiological events that may have led to it (e.g., cardiac dysrhythmias) must be considered. A detailed review of long-term medical conditions and medications, along with their effect on vital signs, is necessary. Risk factors for falls include physical impairments, long-term medication use, dementia, and visual, cognitive, or neurological impairments.

Elderly patients are more prone to sustaining burn injuries due to decreased reaction times, hearing and visual impairment, and inability to escape the burning structure. Burn injury remains the cause of significant mortality.

Airway – Due to loss of protective airway reflexes, airway management in the elderly can be challenging and requires a timely decision to establish a life-saving definitive airway. Opening of the mouth and cervical spine maneuvering may be challenging with arthritic changes. Loose dentures should be removed, while well-fitted dentures should be better left inside. Some patients may be edentulous, making intubation easier, but bag-mask ventilation is difficult.

While performing rapid sequence intubation, it is recommended to lower the doses of barbiturates, benzodiazepine, and other sedatives to 20% to 40% to avoid the risk of cardiovascular depression.

Breathing – Elderly patients have decreased compliance of the lungs and the chest wall, which leads to increased breathing work, placing them at a higher risk for respiratory failure. Aging also results in suppressed heart rate during hypoxia, and respiratory failure may present alongside.

Circulation – These patients may have increasing systemic vascular resistance in response to hypovolemia, given that they may have a fixed heart rate and cardiac output. Also, an acceptable blood pressure reading may truly indicate a hypotensive state, as most elderly patients have preexisting hypertension.

A systolic blood pressure of 110 mm Hg is used as a threshold for identifying hypotension in adults over 65.

Several variables, namely base deficit, serum lactate, shock index, and tissue-specific lab markers, can be used to assess for hypoperfusion. Consider early use of advanced monitoring of fluid status, such as central venous pressure (CVP), echocardiography, and bedside ultrasonography, to guide resuscitation.

Disability – Traumatic brain injury is one of the significant complications among the elderly. The dura becomes more adherent to the skull with age, which increases the risk of epidural hematoma. Moreover, these patients are commonly prescribed anticoagulant and antiplatelet medications, which puts these individuals at a higher risk of developing intracranial hemorrhage. Therefore, a very low threshold is indicated for further CT scan imaging in ruling out acute intracranial and spinal pathologies.

Exposure – Increased risk of hypothermia due to loss of subcutaneous fat, nutritional deficiencies, chronic medical illnesses, and therapies. Complications of immobility, such as pressure injuries and delirium, may develop.

Rapid evaluation and relieving from spine boards and cervical collars will help to reduce these injuries.

Pregnant [10]

Evaluation and management of pregnant individuals can be challenging due to the physiological and anatomical changes that affect nearly every organ system in the body. Therefore, knowledge of the physiological and anatomical changes during pregnancy regarding the mother and the fetus is important to provide the best and most appropriate resuscitation and care for both.

The best initial treatment for the fetus is by providing optimal resuscitation of the mother.

Female patients in the reproductive age who present to the ED must be considered pregnant until proven by a definitive pregnancy test or ultrasound exam.

A specialized obstetrician and surgeon should be consulted early in the assessment of pregnant trauma patients; if not available, early transfer to an appropriate facility should be sought.

The uterus is an intrapelvic organ until the 12th week of gestation, around 34 to 36 weeks when it rises to the level of the costal margin. This makes the uterus and its contents more susceptible to blunt abdominal trauma, whereas the bowel remains somewhat preserved. Nevertheless, penetrating upper abdominal trauma in the late gestational period can cause complex intestinal injury due to displacement.

Amniotic fluid embolism and disseminated intravascular coagulation are significant complications of trauma in pregnancy. In the vertex presentation, the fetal head lies in the pelvis, and any fracture of the pelvis can result in fetal skull fracture or intracranial injury.

A sudden decrease in maternal intravascular volume can lead to a profound increase in uterine vascular resistance, thus reducing fetal oxygenation regardless of normal maternal vital signs.

The volume of plasma increases throughout pregnancy and peaks by 34 weeks of gestation. Physiological anemia of pregnancy occurs when there is an increase in red blood cell (RBC) volume, leading to decreased hematocrit levels. In normal, healthy pregnant individuals, blood loss of 1200 to 1500 ml can occur without showing any signs or symptoms of hypovolemia. Nonetheless, this compromise may be seen as fetal distress, indicated by an abnormal fetal heart rate on monitoring.

Leukocytosis is expected during pregnancy, peaking up to 25,000/mm3 during labor. Serum fibrinogen and other clotting factors may be mildly increased, with shorter prothrombin and partial thromboplastin times. However, bleeding and clotting times remain the same.

During late pregnancy, in a supine position, vena cava compression can cause a decrease in cardiac output by 30 % due to lesser venous return from the lower extremities.

In the third trimester of pregnancy, heart rate increases up to 10-15 beats/min than the baseline while assessing for tachycardia in response to hypovolemia. Hypertension, along with proteinuria, indicates the need to manage preeclampsia. Be mindful of eclampsia as a complication during late pregnancy, as its presentation can be similar to a head injury (seizures with hypertension, hyperreflexia, proteinuria, and peripheral edema)

An increase in the tidal volume causes increases in the minute ventilation and hypocapnia (PaCO2 of 30 mm Hg), which is common in the later gestational period. Therefore,

Maintaining adequate arterial oxygenation during resuscitation as oxygen consumption increases during pregnancy is also important.

By the seventh month of gestation, the symphysis pubis widens to about 4 to 8 mm, and sacroiliac joint spaces increase. These alterations must be kept in mind while evaluating pelvic X-ray films during trauma. Additionally, the pelvic vessels that surround the gravid uterus can become engorged, leading to large retroperitoneal hemorrhage after blunt trauma with pelvic fractures.

Every pregnant patient who has sustained major trauma must be admitted with appropriate obstetric and trauma facilities.

Pregnant individuals may present to the ED with non-obstetric causes such as intentional (intimate partner violence, suicide attempt) and unintentional trauma (MVC, fall), and obstetric causes such as ectopic pregnancy, vaginal bleed, contractions, abdominal pain, decreased fetal movement, etc.

“To optimize outcomes for the mother and fetus, assessment and resuscitation of the mother is performed first and then the fetus, before proceeding for secondary survey of the mother.”

Primary Survey - Mother

Airway – Ensure the patient has a patent and maintainable airway with adequate ventilation. In cases where intubation is necessary, maintain appropriate PaCO2 levels according to the patient’s gestational age. Due to the superior displacement of abdominal organs and delayed gastric emptying, there is an increased risk of aspiration during intubation.

Breathing – These patients may have an increased rate of respiration due to pressure effects or hormonal changes. Pulse oximetry and arterial gas must be monitored as adjuncts. It must be remembered that normal maternal bicarbonate levels will be low to compensate for the respiratory alkalosis.

Circulation – Attempt to manually reposition the uterus towards the left side to relieve the pressure on the inferior vena cava and improve the venous return.

Since pregnant individuals have increased intravascular volumes, they can lose a large amount of blood before the onset of tachycardia, hypotension, or other signs of hypovolemia. Therefore, it is essential to remember that the fetus and the placenta are deprived of perfusion, leading to fetal distress while the maternal conditions appear stable.

Administer crystalloid IV fluids and type-specific blood. Vasopressors must be used only as a last resort to raise maternal blood pressure, as these agents can further cause a reduction of the uterine blood flow, leading to fetal hypoxia.

Primary Survey - Fetus

Leading causes of fetal demise include maternal shock and death, followed by placental abruption.

Assess for signs of abruptio placentae (vaginal bleeding, uterine tenderness, frequent uterine contractions, uterine tetany, and irritability). Another rare injury is the uterine rupture (abdominal tenderness, rigidity, guarding or rebound tenderness, abnormal fetal lie, etc.) accompanying hypovolemia and shock.

By 10 weeks of gestation, fetal heart tones can be assessed by Doppler ultrasound, and beyond 20-24 weeks of gestation, continuous fetal monitoring with a tocodynamometer must be performed. At least 6 hours of continuous monitoring in patients with no risk factors for fetal death is recommended, and 24 hours of monitoring in patients with a high risk of fetal death.

Secondary Survey

Perform the secondary survey for non-pregnant individuals, as mentioned.

An obstetrician should ideally examine the perineum, including the pelvis. The presence of amniotic fluid in the vagina, PH greater than 4.5, indicates chorioamniotic membrane rupture.

All pregnant patients with vaginal bleeding, uterine irritability, abdominal tenderness and pain, signs and symptoms of shock, fetal distress, and leakage of amniotic fluid should be admitted for further care.

All pregnant trauma patients with Rh-negative blood group must receive Rh immunoglobulin therapy unless the injury is remote from the uterus within 72 hours of injury.

Obese Patients [10]

In the setting of trauma, procedures such as intubation can be challenging and dangerous due to their anatomy. Diagnostic investigations such as E-FAST, DPL, and CT scans may also be challenging. Moreover, most of these patients have underlying cardiopulmonary diseases, which hinders their ability to compensate for the stress and injury.

Athletes [10]

Owing to their prime conditioning, they may not exhibit early signs such as tachycardia or tachypnea in shock cases. Additionally, they usually have low systolic and diastolic blood pressure.

Revisiting Your Patient

Let’s get back to the patient we discussed earlier and start assessing him:

Airway – The patient maintains his airway but finds breathing hard. Intervention: Apply 15L Oxygen via a nonrebreather mask.

Breathing—A strap mark contusion is seen with multiple bruises. His chest expansion is asymmetrical, with reduced breath sounds on the right side of his chest. There is a dull percussion note on the right lower half of his chest. He maintains oxygen saturation. Intervention: Prepare for chest tube insertion on the right side.

Circulation – Heart sounds are muffled with marked engorgement of the external jugular veins in the neck, a good pulse still palpable in his left radial, but cold clammy extremities. His pulse is 128/min, and his blood pressure is 92/50 mm Hg. Bedside ultrasound FAST (Focused Assessment Sonography in Trauma) shows a pericardial tamponade. Intervention: IV access was gained with two large-bore IV cannulas, blood was drawn for labs, the massive transfusion protocol for blood products was activated, a Foley catheter was inserted to monitor urinary output, and the surgery team was on board to plan for emergent pericardiocentesis.

Disability – Patient’s GCS remains 15, unremarkable pupillary examination and POC glucose is 7 mmol/dl.

Exposure – you notice the strap mark on his chest secondary to his seatbelt restraint, and the multiple bruises. The remaining evaluation is unremarkable, with no head, spine, abdomen, or limb injury.

Adjunct investigations – A portable chest x-ray shows increased cardiac shadow and multiple bilateral rib fractures. There is opacification in the right lung [12].

Discussion

This patient sustained a blunt trauma leading to pericardial tamponade and right-sided hemothorax, leading to hypovolemic shock. The most common cause of shock in a trauma patient is hypovolemic shock due to hemorrhage. However, other types of shock like cardiogenic shock (due to myocardial dysfunction), neurogenic shock (due to sympathetic dysfunction), or obstructive shock (due to tension pneumothorax, obstruction of great vessels) can occur.

Early signs of shock include tachycardia, which is the body’s attempt to preserve cardiac output and cool peripheries, and reduced capillary refill time caused by peripheral vasoconstriction. This is caused by the release of catecholamine and vasoactive hormone, which leads to increased diastolic blood pressure and reduced pulse pressure. For this reason, measuring pulse pressure rather than systolic blood pressure allows earlier detection of hypovolaemic shock, as the body can lose up to 30% of its blood volume before a drop in systolic blood pressure is appreciated.

Initiate fluid resuscitation in these patients and do not wait for them to develop hypotension.
The main aim is to maintain organ perfusion and tissue oxygenation. In children, start with crystalloid fluid boluses of 20 ml/kg, and in adults, an initial 1 L can be given. In patients who have sustained a major blood loss, consider initiating the Massive Transfusion Protocol (MTP) for blood products as soon as possible.

A few current trauma guidelines have recommended ‘permissive hypotension’ or ‘balanced resuscitation,’ where the principle is to stabilize any blood clots that may have been formed, and aggressive blood pressure resuscitation may disrupt this ‘first formed clot’ and may contribute to further hemorrhage.

To evaluate response to fluid resuscitation, assess the level of consciousness, improvement in tachycardia, skin temperature, capillary refill, and urine output (>0.5 ml/kg/hour in adults).
Besides administering packed red blood cells, do not forget to transfuse platelets, fresh frozen plasma, or cryoprecipitate, as large blood loss can develop coagulopathy in 30% of these injured patients. Tranexamic acid (TXA), an antifibrinolytic, can be utilized in addition as a 1 g bolus over 10 minutes followed by 1 g over 8 hours within 3 hours of trauma without an increased risk of thromboembolic events [11].

This systematic approach focuses on identifying and treating this hemorrhagic shock case. Bedside adjuncts such as FAST examination and portable chest X-ray can provide valuable clues to the cause of shock. A trauma CT scan is only performed once the patient is stable enough to go to the scan room.

This patient’s vital signs improve slightly but remain unstable, and blood is kept draining into the chest drain. The patient is taken to the operation theatre for an emergency thoracotomy [12].

Authors

Roxanne R. Maria

Hamid A. Chatha

Listen to the chapter

References

Initial Assessment of Emergency Department patients, The Royal College of Emergency Medicine, Feb 2017
World Health Organization. BASIC EMERGENCY CARE : Approach to the Acutely Ill and Injured.World Health Organization; 2018.
Thim T. Initial assessment and treatment with the airway, breathing, circulation, disability, exposure (ABCDE) approach. International Journal of General Medicine. 2012;5(5):117-121. doi:https://doi.org/10.2147/IJGM.S28478
Peate I, Brent D. Using the ABCDE Approach for All Critically Unwell Patients. British Journal of Healthcare Assistants. 2021;15(2):84-89. doi:https://doi.org/10.12968/bjha.2021.15.2.84
Schoeber NHC, Linders M, Binkhorst M, et al. Healthcare professionals’ knowledge of the systematic ABCDE approach: a cross-sectional study. BMC Emergency Medicine. 2022;22(1). doi:https://doi.org/10.1186/s12873-022-00753-y
Learning Objectives. https://www.moh.gov.bt/wp-content/uploads/moh-files/2017/10/Chapter-2-Emergency-Patient-Assessment.pdf
Resuscitation Council UK. The ABCDE Approach. Resuscitation Council UK. Published 2021. https://www.resus.org.uk/library/abcde-approach#:~:text=Use%20the%20Airway%2C%20Breathing%2C%20Circulation
Management of trauma patients – Knowledge @ AMBOSS. http://www.amboss.com. https://www.amboss.com/us/knowledge/Management_of_trauma_patients/
Oxford Medical Education. ABCDE assessment. Oxford Medical Education. Published 2016. https://oxfordmedicaleducation.com/emergency-medicine/abcde-assessment/
HENRY SM. ATLS Advanced Trauma Life Support 10th Edition Student Course Manual, 10e. 10th ed. AMERICAN COLLEGE OFSURGEO; 2018.
Walls RM, Hockberger RS, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen’s Emergency Medicine : Concepts and Clinical Practice. Elsevier; 2.
Eamon Shamil, Ravi P, Mistry D. 100 Cases in Emergency Medicine and Critical Care. CRC Press; 2018.

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.

Maxillofacial Trauma (2024)

November 6, 2024November 15, 2024 ~ iEM Education Project Team ~ Leave a comment

by Maitha Ahmad Kazim & David O. Alao

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	Ask for allergies Ask for if/when they took Acetaminophen at home
Ibuprofen	mild-moderate pain (can be given with Acetaminophen)	600 mg PO Max Dose: 3,200 mg daily	q6h	Can cause GI upset and increase risk of GI bleed Renal insufficiency
Hydromorphone	Moderate – severe pain	0.5-4 mg IV/IM/SC Max Dose: n/a	q4-6h	Risk of respiratory depression Risk of addiction and abuse
Morphine sulfate	Moderate – severe pain	2.5-10 mg IV/IM/SC Max Dose: n/a	q2-6h	Risk of respiratory depression Risk of addiction and abuse Hypotension
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.	Extrapyramidal side effects If acute dystonic reactions occur, 50 mg of diphenhydramine may be injected IM.
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	Increased risk of QT prolongation, which increases the risk of cardiac arrhythmia and cardiac arrest.
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)	Ask for allergies Ask if they have taken any antibiotic recently. Hives and skin rash

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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References

Lalloo R, Lucchesi LR, Bisignano C, et al. Epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the Global Burden of Disease 2017 study. Inj Prev. 2020;26(Supp 1):i27-i35. doi:10.1136/injuryprev-2019-043297
Singaram M, G SV, Udhayakumar RK. Prevalence, pattern, etiology, and management of maxillofacial trauma in a developing country: a retrospective study. J Korean Assoc Oral Maxillofac Surg. 2016;42(4):174. doi:10.5125/jkaoms.2016.42.4.174
Nalliah RP, Allareddy V, Kim MK, Venugopalan SR, Gajendrareddy P, Allareddy V. Economics of facial fracture reductions in the United States over 12 months. Dent Traumatol Off Publ Int Assoc Dent Traumatol. 2013;29(2):115-120. doi:10.1111/j.1600-9657.2012.01137.x
Pappachan B, Alexander M. Biomechanics of Cranio-Maxillofacial Trauma. J Maxillofac Oral Surg. 2012;11(2):224-230. doi:10.1007/s12663-011-0289-7
Sharifi F, Department of Oral & Maxillofacial Surgery, Mashhad University of Medical Sciences, Mashhad, Iran., Samieirad S, et al. The Causes and Prevalence of Maxillofacial Fractures in Iran: A Systematic Review. WORLD J Plast Surg. 2023;12(1):3-11. doi:10.52547/wjps.12.1.3
Van Gijn D. Tips for GP trainees working in oral and maxillofacial surgery. Br J Gen Pract. 2012;62(594):50-51. doi:10.3399/bjgp12X616490
Lynham A, Tuckett J, Warnke P. Maxillofacial trauma. Aust Fam Physician. 2012;41(4):172-180.
Philip MR, Soumithran CS. Prevalence of Neurologic Deficits in Combined Facial and Cervical Spine Injuries: A Retrospective Analysis. Craniomaxillofacial Trauma Reconstr. 2021;14(1):49-55. doi:10.1177/1943387520940182
Saigal S, Khan MM. Primary Assessment and Care in Maxillofacial Trauma. Oral and Maxillofacial Surgery for the Clinician. 2021:983-995. doi:10.1007/978-981-15-1346-6_48
Truong T. Initial Assessment and Evaluation of Traumatic Facial Injuries. Semin Plast Surg. 2017;31(02):069-072. doi:10.1055/s-0037-1601370
Mukherjee S, Abhinav K, Revington P. A review of cervical spine injury associated with maxillofacial trauma at a UK tertiary referral centre. Ann R Coll Surg Engl. 2015;97(1):66-72. doi:10.1308/003588414X14055925059633
Patel BC, Wright T, Waseem M. Le Fort Fractures. In: StatPearls. StatPearls Publishing; 2023. Accessed August 12, 2023. http://www.ncbi.nlm.nih.gov/books/NBK526060/
Peng N, Su L. Progresses in understanding trauma-induced coagulopathy and the underlying mechanism. Chin J Traumatol. 2017;20(3):133-136. doi:10.1016/j.cjtee.2017.03.002
Das D, Salazar L. Maxillofacial Trauma: Managing Potentially Dangerous And Disfiguring Complex Injuries. Emerg Med Pract. 2017;19(4):1-24.
Meara DJ. Diagnostic Imaging of the Maxillofacial Trauma Patient. Atlas Oral Maxillofac Surg Clin North Am. 2019;27(2):119-126. doi:10.1016/j.cxom.2019.05.004
Forrest CR, Lata AC, Marcuzzi DW, Bailey MH. The role of orbital ultrasound in the diagnosis of orbital fractures. Plast Reconstr Surg. 1993;92(1):28-34. doi:10.1097/00006534-199307000-00004
Sharma R, Parashar A. Unfavourable outcomes in maxillofacial injuries: How to avoid and manage. Indian J Plast Surg. 2013;46(2):221. doi:10.4103/0970-0358.118597
Krausz AA, Krausz MM, Picetti E. Maxillofacial and neck trauma: a damage control approach. World J Emerg Surg. 2015;10(1):31. doi:10.1186/s13017-015-0022-9
Hutchison I, Lawlor M, Skinner D. ABC of major trauma. Major maxillofacial injuries. BMJ. 1990;301(6752):595-599. doi:10.1136/bmj.301.6752.595
Barak M, Bahouth H, Leiser Y, Abu El-Naaj I. Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach. BioMed Res Int. 2015;2015:724032. doi:10.1155/2015/724032
Spurrier E, Johnston A. Use of Nasogastric Tubes in Trauma Patients – A Review. J R Army Med Corps. 2008;154(1):10-13. doi:10.1136/jramc-154-01-04
Jose A, Nagori S, Agarwal B, Bhutia O, Roychoudhury A. Management of maxillofacial trauma in emergency: An update of challenges and controversies. J Emerg Trauma Shock. 2016;9(2):73. doi:10.4103/0974-2700.179456
Stewart C, Fiechtl JF, Wolf SJ. Maxillofacial trauma: Challenges in ED diagnosis and management. Emerg Med Pract. 2008;10(2):1-18.
Shumate R, Portnof J, Amundson M, Dierks E, Batdorf R, Hardigan P. Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective 10-Year Multicenter Review. J Oral Maxillofac Surg. 2018;76(9):1931-1936. doi:10.1016/j.joms.2017.10.019
Kokko LL, Puolakkainen T, Suominen A, Snäll J, Thorén H. Are the Elderly With Maxillofacial Injuries at Increased Risk of Associated Injuries?. J Oral Maxillofac Surg. 2022;80(8):1354-1360. doi:10.1016/j.joms.2022.04.018