CC
A 49-year-old male is transported to the emergency department (ED) by emergency medical service (EMS) personnel status after a pedestrian-versus-automobile accident. You are called by the trauma team for the evaluation and management of his facial injuries.
HPI
The patient arrives at the ED intubated. The driver of the automobile and another eyewitness report that the patient was walking alongside a busy intersection and suddenly jumped into the path of a vehicle traveling at approximately 35 mph. The front end of the car struck his thighs, and then his face hit the hood and windshield, causing significant damage to the automobile. He was launched several feet into the air and landed in a prone position on the pavement. He had a Glasgow Coma Scale (GCS) score of 3 at the scene and was orally intubated by EMS personnel for airway protection. (Airway intubation is warranted for a GCS score of 8 or lower, which is indicative of a severe head injury.) When you arrive in the ED, the patient is being actively resuscitated by the trauma team according to the Advanced Trauma Life Support (ATLS) protocol, and the orthopedic team is evaluating multiple extremity fractures.
PMHX/PDHX/medications/allergies/SH/FH
The patient’s histories are unknown. (Information may be obtained from family members, when present.)
Examination
The initial evaluation of a trauma patient should be dictated by the ATLS protocol.
Primary survey
Airway and cervical spine control. The patient has been orally intubated, and a transport cervical collar is in place. (In a review of 563 patients with maxillofacial injuries, Haug and associates found that concomitant cervical spine fractures occurred in 2% of patients. Of those with cervical spine fractures, 91% had mandibular fractures. Bagheri and colleagues found a 1.5% incidence of cervical spine fractures in a series of 67 patients with isolated midfacial fractures.)
Breathing and oxygenation. The oral endotracheal tube is in good position (confirmed by portable chest radiograph) on mechanical ventilation. The right hemithorax shows no chest rise or breath sounds and is hypertympanic to percussion (indicative of a pneumothorax, also confirmed by portable chest radiograph). A chest tube is placed to reexpand the right lung. Oxygen saturation is 90% on 100% inspired oxygen (suggestive of a ventilation-perfusion mismatch).
Circulation and hemorrhage control. Blood pressure is 90/70 mm Hg, and heart rate is 125 bpm (moderate hypotension and tachycardia consistent with class III shock). (Class III hypovolemic shock is indicative of a 30%–40% loss of blood volume, which is characterized by a heart rate >120 bpm; decreases in systolic blood pressure, mean arterial blood pressure, pulse pressure, and urine output [5–15 mL/hr]; and altered mental status). A small amount of bleeding is observed from the nasopharynx and is easily controlled with bilateral nasal packs. The magnitude of bleeding does not clinically correlate with the estimated blood loss and volume depletion (raising suspicion for other sources of bleeding). The abdomen is soft and nondistended, and the focused abdominal sonography for trauma (FAST) is negative (FAST examination is used in the hypotensive blunt trauma patient and evaluates the perihepatic, pericardiac, perisplenic, and pelvic windows for the presence of free intraperitoneal fluid or cardiac tamponade); this rules out intraabdominal hemorrhage (hypovolemic) and cardiac tamponade (obstructive) as the source of shock. Bilateral femoral deformities (each femur fracture can be a source of 1.5–2 L of blood loss) and other open extremity fractures can be a source of significant blood loss and hypovolemic shock. Fractures should be reduced and stabilized to reduce the amount of hemorrhage in the initial resuscitation phases. Fluid resuscitation should begin with crystalloid intravenous (IV) fluid boluses to maintain organ perfusion. Transfusion of packed red blood cells should be considered in class III hemorrhagic shock.
Disability and dysfunction. On the AVPU (A, awake; V, responds to voice; P, responds to pain; U, unresponsive) scale, the patient is unresponsive (off sedation) and has a GCS score of E1 + M1 + V1T = 3T. Pupils are equal, 7 mm, with a sluggish reaction to light. (Large pupils with a sluggish reaction to light reflex may indicate a closed head injury and elevated intracranial pressure [ICP].) Sedation should be discontinued for an accurate assessment of mental status as needed. Initial head computed tomography (CT) scan reveals moderate contusions in the frontal and occipital lobes (coup, countercoup injury, indicative of a rapid acceleration-deceleration mechanism). A Camino bolt is placed to monitor the ICP, which reveals a mildly elevated opening pressure at 22 mm Hg (normal ICP is ≤15 mm Hg).
Exposure and environmental control. The patient’s clothing has been removed, and a warm blanket and other warming devices are used to prevent hypothermia.
Secondary survey
The AMPLE history (allergy, medications, past medical history, last meal, events leading to presentation) is taken from available sources.
General. The patient is a well-developed male who is intubated and sedated and has a cervical collar in place.
Neurologic. The GCS score is 3T (off sedation). Pupils are 7 mm, equal, and sluggish. (This parameter was covered during the primary survey but should be repetitively monitored for changes.) The ICP-monitoring device (e.g., intraparenchymal Camino bolt or external ventriculostomy drain) gives a precise, moment-by-moment assessment of ICPs. A sustained ICP greater than 25 mm Hg warrants intervention to reduce the pressure (IV mannitol, hyperosmolar therapy with 3% NaCl, elevation of head of bed, hyperventilation to reduce the Pa co 2 to the low range of normal). Therapy is aimed at not only reducing ICP (<20 mm Hg) but also at maintaining cerebral perfusion pressures (cerebral perfusion pressure = mean arterial pressure − ICP), which should be maintained greater than 70 mm Hg (35% reduction in mortality rate) to prevent secondary brain injury. Invasive hemodynamic monitoring is indicated when hyperosmolar therapy is initiated to maintain an acceptable blood pressure and cerebral perfusion pressure (mortality rate increases 20% for each 10–mm Hg loss of cerebral perfusion pressure).
Maxillofacial. There is significant upper and lower facial edema. A 2-cm full-thickness laceration extends over the bridge of the nose (indicating blunt trauma to the upper midface), and there is a 5-cm full-thickness stellate laceration over the lower lip and chin.
Eyes. There is significant periorbital edema. Visual acuity cannot be assessed. The patient has bilateral periorbital ecchymosis (raccoon eyes, indicative of anterior basilar skull fracture) and bilateral subconjunctival hemorrhage and chemosis. Intercanthal distance is 36 mm without blunting of the medial canthus. (An increased intercanthal distance is indicative of a naso-orbital-ethmoid [NOE] fracture or avulsion of the medial canthal tendon. Normal intercanthal distance is 30–34 mm and varies among races and genders.) The bowstring test result (a clinical test for evaluation of the medial canthal attachment) is negative. Bilateral step deformities are present at the lateral and inferior orbital rims (step deformity and bony crepitus indicate the presence of fractures).
Nose. The nasal bridge demonstrates crepitus with gross mobility. The endonasal examination reveals an edematous nasal mucosa with mild bleeding. The anterior nasal septum is midline with no septal hematoma. (Septal hematoma requires immediate incision and drainage to prevent necrosis of the septal cartilage and potential perforation and saddle-nose deformity.) No cerebrospinal fluid (CSF) rhinorrhea or otorrhea is noted. The maxilla is grossly mobile with bony crepitus at the anterior maxillary walls and the zygomaticomaxillary (ZM) buttresses. No step deformity or crepitus is appreciable at the zygomatic arches bilaterally. (This does not exclude the possibility of fractures.)
Intraoral. There is bilateral maxillary vestibular ecchymosis (indicative of fractures of the ZM buttresses). There are multiple missing maxillary teeth and a step deformity with an associated gingival laceration between the left mandibular lateral and central incisors (teeth #23 and #24), with gross mobility of the mandibular segments. The patient has an anterior open bite with no distinct mandibular posterior stop and bilateral posterior prematurities (indicative of bilateral condylar fractures or Le Fort level fracture), with the oral endotracheal tube exiting between the edentulous spaces. There is ecchymosis at the posterior soft palate bilaterally (Guerin’s sign, indicative of pterygoid plate disjunction or fracture).
Imaging
A plain film radiograph series in the acute setting includes cross-table cervical spine, portable anteroposterior (AP) chest radiography, and an AP pelvis radiograph. Other studies are added as needed, including cervical spine series (in suspected cervical spine injury), thoracic and lumbar spine series, and extremity radiographs (depending on the mechanism of injury).
Axial cut bony window CT scans (with coronal reconstructions) are the gold standard radiographic examination for midfacial fractures. Direct coronal views are useful but should be avoided in patients with suspected cervical spine injury. (The patient’s head needs to be hyperextended for a direct coronal CT scan.) Three-dimensional (3D) reconstructions are helpful adjuncts because they provide the most graphic representation of the fractures, degree of displacement, and orientation of fragments. A panoramic radiograph is always helpful; however, in the unstable patient with cervical–thoracic–lumbar spine precautions, this is not likely to be possible.
In the current patient, head and facial helical CT scans without contrast were obtained after the primary and secondary surveys were completed. The head CT scan revealed moderate frontal lobe and occipital lobe contusions without evidence of intracerebral hemorrhage or midline shift. (These scans should be repeated in 12–24 hours to monitor for any changes.) The fine cut axial face CT scan revealed bilateral nasal bone fractures, fractures of the lateral orbital rims and walls, and bilateral zygomatic arch fractures ( Fig. 59.1 A and B). Fractures at the pterygoid plates and along the anterior and posterior maxillary sinus and lateral nasal walls also were seen ( Fig. 59.1 C). Coronal reconstruction views anteriorly demonstrated fractures at the nasofrontal junction, a Le Fort I fracture, and a midpalatal split ( Fig. 59.1 D). Coronal views of the midface demonstrated severe comminution of the midface, including at the NOE, orbital floors, and zygomaticofrontal junction ( Fig. 59.1 E). Scans of the mandible demonstrated bilateral condylar neck fractures ( Fig. 59.1 F; also see Fig. 59.1 C) and a midline mandibular symphysis fracture. Fig. 59.1 G shows the 3D reconstructed view, which also demonstrated fracture of the anterior table of the frontal sinus, confirmed on the axial views.
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