Facial injury complications:

A facial injury can present several difficulties for a clinician, especially with a polytrauma patient who is unwell. The issue is due to the potential airway and breathing compromise that a significant facial injury can cause. How you treat the patient will depend on the severity of injury, their GCS level, and other contributing factors. Here we will look at scenarios where major facial trauma and patient compromise has occurred:

Oral and/or nasal bleeding – Heavy bleeding from the mouth and/or nose can cause airway compromise in a patient who may have suffered major trauma and has a reduced level of consciousness. Postural drainage and/or suction can be used to help maintain airway patency. C-spine consideration will also be needed when performing any manoeuvres.

Swelling – Following major trauma to the face, there may also be significant swelling around the mouth and nose. This may make it difficult to maintain a Bag Valve Masks (BVM) seal when trying to ventilate the patient and may require further stepwise airway management and requests for advanced clinician support.

Loose debris – Impact to the face may cause teeth/dentures/fittings to come loose and tissues to tear and lacerate. This would cause further debris to compromise the airway which would require clearing.

Fractures/dislocations – Fractures and dislocations can cause significant deformity to the facial structure. Injury to the face, nose, or jaw may cause significant swelling and structural alteration, making a BVM seal very difficult. Manual airway positioning may be required with further stepwise airway management and advanced clinician support.

Facial deformity and destruction – A major facial injury may cause significant facial deformity and destruction, potentially causing complete airway obstruction. A stepwise airway approach will be required to manage the patient with request for advanced clinician support. Where deformity and destruction is too great, there may need to be consideration for needle cricothyroidotomy.

Within a major facial trauma incident, it is likely that several of the above injury scenarios will be present, causing a significant airway challenge for the clinician.

Management:

As major facial injury and major head injury will be closely linked, there are several corresponding factors and considerations that need to be made when working through the primary survey:

Catastrophic Haemorrhage:

Stemming any catastrophic haemorrhage is vital to maintain any homeostatic stability of the patient.

Airway with C-spine consideration:

Maintaining a patent airway through a stepwise approach will help stem hypoxic damage and cellular death. With significant facial trauma it may be difficult to manage the patients’ airway. Utilise a stepwise airway approach and request further advanced clinical support if needed. Remember there may be a likely C-spine injury and the use of a cervical collar may have to be omitted or altered to stop further increase in ICP where there is an associated TBI.

Breathing:

Management of breathing will further assist in reducing hypoxic damage. Use oxygen therapy where there is major trauma. Ventilation may be difficult where there is significant facial trauma, and advanced clinical support may be required. Ventilation and recording of capnography can be used to maintain normocapnic levels and reduce the risk of further secondary brain injury through hyper or hypocapnia.

Circulation:

Review further haemorrhage control where there may be internal concerns. Apply pelvic binder, TXA for major head injury and bleeding following your ambulance service guidelines. Look at fluid administration to maintain systolic blood pressures to keep CPP. A targeted systolic of 60 mmHg or central carotid pulse should be aimed for in penetrating torso trauma, a systolic of 90 mmHg or peripheral radial pulse in blunt trauma or penetrating limb trauma, and a systolic of 110 mmHg in isolated head injury.

Disability:

Maintain patients’ temperature and cover to avoid heat loss, review blood glucose levels and treat any unusual findings, review GCS level, review any seizure activity and treat if required.

Evacuate:

Consider early evacuation of the patient to further care, request specialist support if needed and available. Consider a 30⁰ head up position when transporting the patient as this can reduce the effects of increased ICP. This may be difficult though within the pre-hospital setting and where a patient is immobilised. Use clinical judgement and consideration for the scenario and setting in front of you.