Larry L. Cunningham, Jr. and Ruba Khader

Outline

• Immediate, resuscitative, or emergent treatment required: Facial injuries that are life-threatening (causing airway obstruction or severe hemorrhage) or sight-threatening (causing increases in intraocular pressure) and that require immediate interventions aimed at securing the airway, stopping the hemorrhage, or relieving the intraocular pressure via cantholysis.

• Treatment required within a few hours: Facial injuries that are extremely contaminated in a patient who is hemodynamically stable.

• Treatment required within 24 hours: Some facial fractures and lacerations.

• Treatment can be delayed for more than 24 hours if necessary: Most other facial fractures.

Airway (With Cervical Spine Protection)

If a patient has an unfavorable bilateral mandibular fracture causing airway obstruction, the maxillofacial surgeon can assist by simply stabilizing the fracture with a bridle wire. By restoring spontaneous breathing, this maneuver may eliminate the need for endotracheal intubation.

Breathing and Ventilation

If the patient’s Glasgow Coma Scale score is lower than 15, performing a procedure to stabilize a bilateral mandibular fracture will permit the patient to breathe spontaneously and will reduce the likelihood of airway obstruction if the patient’s level of consciousness decreases. This procedure will allow the patient to breathe and ventilate without the aid of an advanced airway; in turn, the absence of endotracheal intubation allows neurologic assessment of the patient at regular intervals.

Circulation

The face and neck are heavily vascularized regions of the body and this large blood supply facilitates a level of healing that is unmatched elsewhere in the body. On the other hand, however, this robust vascularity means that injuries to this region of the body can produce copious bleeding that requires immediate attention. A few key examples follow.

Disability

Ocular examination is a routine part of the primary survey and includes pupil size, reactivity to light, and symmetry. In addition, the examiner should rule out a relative afferent pupillary defect (RAPD, or Marcus Gunn pupil) and palpate the globe (hard or soft).⁷ These elements of the eye examination can be performed quickly and easily and yield a large amount of information.

Exposure

In the maxillofacial region, any dentures or other removable appliances that impede a clear view of the site of potential bleeding should be removed.

History of Present Illness

It can be difficult to obtain a history from the trauma patient; often, information must be gathered from the prehospital personnel and the patient’s family members. The following points should be addressed when the history is obtained (AMPLE is a familiar mnemonic)⁷:

Intuitively, a knowledge of the patient’s medical history, medications, and allergies helps determine whether modifications in management may be necessary. The last meal and pregnancy status of the female patient are important pieces of information, primarily as they relate to possible timing of surgery and to the evaluation and safety of the fetus.

Certain mechanisms of injury should produce a high level of suspicion for distinct types of trauma. For example, a history of a decelerating injury (restrained passenger in a motor vehicle accident [MVA]) should lead to a high suspicion of serious life-threatening consequences caused by shearing forces (e.g., lung or aortic injuries).⁷ Knowledge of the mechanism of injury also assists the surgeon in identifying specific maxillofacial injuries. Blunt injuries to the midface, for example, should prompt the performance of a thorough orbital examination and appropriate radiologic imaging for a proper diagnosis.

Review of Systems

When the trauma patient is awake and oriented, a detailed review of systems (ROS) is invaluable because it directs the examiner’s attention to the site and type of injury. Many physical examination textbooks provide examples of various methods for completing the ROS; every provider should develop and follow his or her own routine to avoid missing important information.

A full-body review of systems should be performed. Table 11-1 is a suggested sequence for performing a head and neck ROS. The ROS allows the inference of various levels of severity of injuries. If the patient has a history of clear discharge from the nose (rhinorrhea) or ears (otorrhea), a fracture of the base of the skull should be suspected until ruled out. If the patient has a history of loss of consciousness, amnesia, vomiting, headaches, or seizure activity after the traumatic incident, a traumatic brain injury should be suspected and a neurosurgical consultation should be requested. Loss of vision or change in visual acuity is another serious symptom that should prompt rapid intervention and consultation with ophthalmology. If the patient reports a change in the dentition or occlusion that is associated with pain and limited mouth opening, a mandibular fracture should be suspected.

Clinical Examination