September 2016 – EM Clerkship, LLC

Basic Approach to Facial Injury

Step 1: Airway
- Indications for intubation after trauma
  - Burns to the airway
  - Rapidly expanding hematoma
  - GCS <8
Step 2: CT Maxillofacial Without Contrast
Step 3: Supportive Care
- Stop bleeding
  - Apply pressure
  - Control epistaxis
    - Caution advised with packing if patient has basilar skull fracture
- Ice
- Analgesics
Step 4: Antibiotics
- Common indications
  - Fractures of a sinus
  - Open fractures
Step 5: Consider Consulting the Appropriate Specialist
- Eye trauma -> Ophthalmology
- ENT trauma -> ENT
- Oral/Dental trauma -> Oral/maxillofacial surgery or dentistry

Six Key Facial Injuries

Frontal bone
- Fractures of the INTERNAL frontal sinus wall = BAD
Eyes and orbits
- “Blowout” fractures with entrapment of the extra-occular muscles = BAD
Nose
- Septal hematoma = BAD
Zygoma (Cheekbone)
- Zygomaticomaxillary complex fracture (aka Tripod fracture) = BAD
Maxilla (Upper jaw)
- Le Fort fractures = BAD
Mandible (Lower jaw)
- Open fractures (intraoral laceration) = BAD

Additional Reading

Step 1: Consider Your Differential Diagnoses

Step 2: Important Add-ons When Taking History

Step 3: Important Add-ons To Your Physical Exam

GCS Score (MDCalc)
Pupils
Basilar Skull Findings
- Raccoon eyes
- Battle sign
- CSF rhinorrhea
- Hemotympanum

Step 4: Calculate Canadian Head CT Rule

Only apply to patients with…
- Loss of consciousness
- Amnesia to event
- Witnessed disorientation
Exclude patients with
- Blood thinners
- Seizure(s)
- Age <16
High risk criteria
- GCS <15 2 hours post injury
- Suspected open/depressed skull fracture
- Signs of basilar skull fracture
- 2 or more episodes of vomiting
- Age >65
“Moderate” risk criteria
- Retrograde amnesia >30 minutes
- Dangerous mechanism
  - Fall >3 ft
  - Motor vs pedestrian
  - Ejected from MVA

Additional Reading

Month: September 2016