Facial Fracture Management in the Emergency Department Treatment & Management

Updated: May 08, 2020
  • Author: Thomas Widell, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
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Treatment

Prehospital Care

 

 

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Emergency Department Care

ABCs take priority. Reassess airway frequently. Early intubation, before edema occurs, can make airway control much easier than waiting until a problem arises from obstruction. When intubation by oral route is impossible, perform a cricothyroidotomy to secure the airway.

These patients require careful assessment of damaged anatomy, recognizing the unique airway complications associated with facial fractures. Posterior displacement from fractured maxillofacial segments may cause soft tissue collapse and occlude the airway, which may be worsened by the presence of a c-spine collar. Both laryngoscopy and mask ventilation may be challenging. Management of aggressive bleeding should be anticipated. [35]

Maxillofacial fractures may also cause trismus that may resolve with neuromuscular blockade; however, differentiating this from a mechanical obstruction before intubation is required and is often difficult. [35]

Before using paralytics in an intubation, carefully evaluate the ability to manage the airway with a bag and mask or laryngeal airway. If unable to manage the airway, do not paralyze the patient. Fiberoptic guides or bronchoscopic-guided intubation may be an option. If in doubt, prepare for a cricothyrotomy before attempting the airway with either sedation or paralytics.

Avoid the temptation to focus on the obvious facial deformity, thereby failing to perform a complete primary survey. Other life-threatening conditions need to be diagnosed rapidly and appropriate resuscitation undertaken. Follow this with a complete secondary survey.

Evaluation of facial fractures is part of the secondary survey. [1]

Once the cervical spine has been cleared, allow the patient to sit with suction available to facilitate maintenance of the airway.

Epistaxis may require anterior nasal packing to control bleeding. Posterior packing may occasionally be needed.

Drain septal hematomas to avoid necrosis of septal cartilage.

Facial fractures tend to be very painful. Provide adequate analgesia, including oral opioids and NSAIDs. If nasal packing is used, antibiotics are generally used to prevent toxic shock. [19]

Patients with simple nasal fractures can be discharged home with follow-up in 5-7 days when edema has decreased. Avoid delaying follow-up care, because fracture healing may begin prior to a necessary reduction. Give patients epistaxis instructions and instruct them to return if clear fluid from the nose is noted.

Patients with simple zygomatic arch fractures, without trismus or mouth opening problems, can be discharged home with proper follow-up care.

Patients with tripod fractures without eye involvement can be discharged home with appropriate follow-up care.

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Medical Care

Patients with NOE fractures generally require admission to monitor for a CSF leak and observe for signs of meningitis or brain abscess, which are known complications.

Patients with zygomatic arch fractures who have significant trismus or inability to open the mouth may require admission for observation because of potential problems with aspiration or airway obstruction from vomiting.

Patients with tripod fractures with eye involvement generally require admission to ophthalmology.

Patients with Le Fort fractures may require admission for further workup prior to open reduction and internal fixation. Patients also may need a short admission if arch wires are used, because of the risk of obstruction or aspiration should they vomit. During the hospital stay, teach patients how to remove the crossband so the mouth can be opened if they need to vomit.

Patients with multiple traumas should be admitted to a surgeon with trauma experience to coordinate care of all injuries.

The incidence of posttraumatic stress disorder is high in patients with facial injuries, and consultation with a psychiatrist should be considered. [20]

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Complications

Continued CSF leaks can occur, although most stop by 2-3 weeks after the injury.

Meningitis and abscesses are serious infections that can occur when a CSF leak is present. Observe patients closely for signs and symptoms.

Other complications include the following:

  • Sepsis
  • Scars and facial deformity
  • Injury to the infraorbital nerve in tripod and Le Fort II fractures that extends through the infraorbital foramen where the nerve exits
  • Posttraumatic stress disorder [20]
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Prevention

Use of seatbelts and airbags can reduce incidence of facial injuries in motor vehicle accidents. Use of helmets with facial guards can reduce injury in motorcycle accidents and in accidents in such sports as skiing, snowboarding, hockey, and football.

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