Emergency Department Management of Maxillofacial Trauma - Trauma EXTRA Supplement (Trauma CME)

Table of Contents

 

About This Issue

As the incidence of maxillofacial injuries increases worldwide, emergency clinicians need to be knowledgeable in the assessment and management of these patients. The maxillofacial area can be difficult to evaluate, ranging from simple lacerations to complex facial fractures. A systematic approach should be applied to the physical examination such that all concomitant injuries are identified and airway, breathing, and circulation needs of the patient are addressed. In this issue, you will learn:

The various types of nasal/sinus, mandibular, orbital, zygomatic, and maxillary fractures.

What related injuries to be concerned about.

How to recognize and simultaneously manage the “ABCDE’s” of the Advanced Trauma Life Support guidelines.

The systematic approach of a primary and secondary survey of a physical examination.

What diagnostic studies are most useful in patients with maxillofacial injuries, as well as disposition plans.

The indications for specialist consultation or admission.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
   1. Pathophysiology
      1. Nasal Bone Fractures
      2. Mandibular Injuries
      3. Orbital Fractures
      4. Zygomatic Fractures
      5. Maxillary Fractures (Le Fort Fractures)
      6. Frontal Sinus Fractures
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. Primary Survey
      1. Key Historical Questions
   2. Secondary Survey
9. Diagnostic Testing
   1. Laboratory Testing
      1. Cerebrospinal Fluid
   2. Imaging Studies
      1. Computed Tomography
      2. Imaging of the Nose
      3. Imaging of the Mandible
      4. Imaging of the Orbits
      5. Imaging of the Zygoma
      6. Imaging of the Maxilla
      7. Imaging of the Frontal Sinus
10. Treatment
    1. Nasal Fractures
    2. Mandibular Fractures
    3. Mandibular Dislocation
    4. Orbital Fractures
    5. Orbital Compartment Syndrome
    6. Cerebrospinal Fluid Leak
    7. Zygoma Fractures
11. Special Populations
    1. Children
    2. Older Patients
12. Controversies and Cutting Edge
    1. Prophylactic Antibiotics
    2. Ultrasound
13. Disposition
14. Summary
15. Risk Management Pitfalls For Maxillofacial Trauma
16. Time- and Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway for Management of Maxillofacial Trauma in the Emergency Department
19. Tables and Figures
20. References

Abstract

Patients with maxillofacial trauma require careful evaluation due to the anatomical proximity of the maxillofacial region to the head and neck. Facial trauma can lead to life-threatening airway compromise or hemorrhage, or permanent facial deformity. Although the Advanced Trauma Life Support guidelines provide a framework for the management of trauma patients, they do not provide a detailed reference for many subtle or complex facial injuries. In addition to an overview of maxillofacial trauma pathophysiology, associated injuries, and physical examination, this review will also discuss relevant imaging, treatment, and disposition plans.

Case Presentations

A 27-year-old man presents to the ED after a high-speed motorcycle accident...

• He was not wearing a helmet.
• His GCS is 7 on arrival and he is not protecting his airway. You note significant facial trauma and his midface is unstable.
• He has a cervical spinal collar in place.
• As your team gets intubation equipment ready, you consider what might be the best way to manage this patient’s airway.

A 75-year-old-woman is brought to the ED after a mechanical fall...

• She has epistaxis and a visible deformity of her nasal bridge.
• As you hold pressure to control the bleeding, you consider if you should obtain imaging and how to manage her injuries.

An inebriated man who was punched multiple times in the face in an altercation presents to the ED...

• He has significant periorbital swelling around his left eye and a deformity of the jaw.
• After ordering a CT, you wonder if you need to obtain surgical consultation.

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Management of Maxillofacial Trauma in the Emergency Department

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Perry M. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 1: dilemmas in the management of the multiply injured patient with coexisting facial injuries. Int J Oral Maxillofac Surg. 2008;37(3):209-214. (Review article) DOI: 10.1016/j.ijom.2007.11.003

15. * Kucik CJ, Clenney T, Phelan J. Management of acute nasal fractures. Am Fam Physician. 2004;70(7):1315-1320. (Review article) PMID: 15508543

17. * Tuckett JW, Lynham A, Lee GA, et al. Maxillofacial trauma in the emergency department: a review. Surgeon. 2014;12(2):106-114. (Review article) DOI: 10.1016/j.surge.2013.07.001

18. * Ceallaigh PÓ, Ekanaykaee K, Beirne CJ, et al. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 5: dentoalveolar injuries. Emerg Med J. 2007;24(6):429-430. (Review article) DOI: 10.1136/emj.2006.035949

30. * Perry M, Dancey A, Mireskandari K, et al. Emergency care in facial trauma--a maxillofacial and ophthalmic perspective. Injury. 2005;36(8):875-896. (Review article) DOI: 10.1016/j.injury.2004.09.018

31. * Perry M, Morris C. Advanced trauma life support (ATLS) and facial trauma: can one size fit all? Part 2: ATLS, maxillofacial injuries and airway management dilemmas. Int J Oral Maxillofac Surg. 2008;37(4):309-320. (Review article) DOI: 10.1016/j.ijom.2007.11.002

42. * Ceallaigh PÓ, Ekanaykaee K, Beirne CJ, et al. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: advanced trauma life support. Emerg Med J. 2006;23(10):796-797. (Review article) DOI: 10.1136/emj.2006.035931

55. * Dolan KD, Jacoby CG, Smoker WRK. The radiology of facial fractures. Radiographics. 1984;4(4):577-663. (Review article) DOI: 10.1148/radiographics.4.4.577

68. * Kellman RM, Tatum SA. Pediatric craniomaxillofacial trauma. Facial Plast Surg Clin North Am. 2014;22(4):559-572. (Review article) DOI: 10.1016/j.fsc.2014.07.009

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Keywords: maxillofacial trauma, craniofacial trauma, facial trauma, mandibular fracture, maxillary fracture, zygoma fracture, cervical spine injury, nasal fracture, orbital fracture, Le Fort fracture, cranial nerve, blowout fracture, mandibular dislocation, orbital compartment syndrome