Figure 1: Facial bones
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- Discuss the incidence of facial trauma
- Review facial anatomy and physiology
- Discuss assessment and treatment of the facial trauma patient
Facial trauma can result from a wide variety of blunt and penetrating mechanisms ranging from trivial to life-threatening, including motor vehicle collisions, violent altercations, falls from any height, person-to-person collisions, gunshots and stabbings, vehicle vs. pedestrian, vehicle vs. biker, fishhooks, animal bites, sports equipment like baseballs and hockey pucks, and falls secondary to seizures.
Geriatric and pediatric patients have their own unique mechanisms. Kids experience facial trauma running into walls, table and counter edges, other kids, and all sorts of stationary objects like playground equipment. Geriatric patients experience facial trauma secondary to falls because they lack the quick reaction time needed to protect themselves as they fall. We had a case where an 80-year-old male patient stood up quickly from his recliner, felt faint, lost his balance and fell forward, hitting his head on the floor. His face was the first point of impact. His nose was fractured and he had a profuse anterior nose bleed. He simply couldn't react fast enough to brace himself with an outstretched hand.
FACIAL TRAUMA SIGNIFICANCE
Facial bones help protect the brain; house important organs for sight, taste and smell; create the initial passages of the respiratory system; provide the first actions in the digestive process; and are the foundation for communication through facial expressions.1 While in many situations facial trauma only results in lacerations, abrasions or swelling, the results can be significant if it also involves:
- Damage to underlying bone structures
- Traumatic brain injury
- Subdural or epidural bleeding
- Intracranial hemorrhage
- Brain herniation
- Cervical spine injury
- Airway compromise.
A thorough initial assessment, detailed secondary assessment and ongoing monitoring are important to identify traumatic facial injuries, as well as injuries that may be causing or could cause ABC life threats.
FACIAL TRAUMA FREQUENCY
An estimated three million emergency department visits are made per year for facial trauma.2 Since most of them are relatively minor, many of those patients likely self-transport to the ED. As a result, EMS professionals are likely to see fewer than 1% of patients with facial trauma that is significant and/or accompanied by other traumatic injuries.2
Historically, motor vehicle collisions were the leading cause of facial trauma, but increased use of seat belts has seen the number decrease. However, EMS professionals are now likely to encounter MVC patients with less-severe facial pain and bruising secondary to air bag deployment. There may even be simple soft tissue wounds from eyeglasses being pushed into their face by the air bag. Nonetheless, motor vehicle collisions continue to be a leading cause of facial trauma for unrestrained occupants.
Specific types of facial fractures are associated with specific mechanisms and types of symptoms. For example, motor vehicle collisions, physical altercations and falls lead to about 85% of nasal fractures,3 which are the most common type of facial fracture. Fractures to the zygomatic bone are second most common and, predictably, like other facial fractures most often occur to men in their 20s.4,5 Men experience most types of trauma at a greater rate because of a combination of factors that include alcohol and drug intoxication, risk-taking and confrontational behavior, and lower use of safety devices like seat belts.
One study reported that women who are victims of intimate-partner violence are more likely to have upper facial traumatic injuries, including orbital and zygomatic fractures.6 Women in the study who had facial injuries from random assailants, motor vehicle collisions and other causes were more likely to have middle and lower facial injuries.
FACIAL ANATOMY AND PHYSIOLOGY
The face is the anterior surface of the body bounded inferiorly by the chin and underside of the jaw and extending upward to include all of the frontal bone, commonly known as the forehead. Laterally, the face extends to the temporomandibular joint and the lateral edges of the right and left orbits.7 The face does not include the temporal bones or other bones of the skull, or bones of the inner ears. Yet, inspection of drainage from the ears is a component of facial trauma assessment.
Underneath a relatively thin layer of skin and musculature that is highly vascular is a complex array of facial bones. Figure 1 shows the bones of the face. The primary and palpable facial bones are mandible, maxillary bones, nasal bones, zygomatic bones and frontal bone.
The mandible is the only movable bone of the face.1 It is located in the lower third of the face and moves in multiple planes to facilitate chewing and speech. Manipulating the movable mandible to displace the tongue is a basic airway management technique. Collisions, altercations and falls are potential mechanisms for mandible injury.
Two maxillary bones fused at the midline form the upper jaw and extend superiorly to form the lower orbits for the eyes and provide support to nasal structures. The maxillary bones hold the upper teeth, contain the maxillary sinuses, form the upper roof of the mouth, and create the floor and lateral walls of the nasal cavity.1 The maxillary bones do not move and are fused to other facial bones that make up the middle third of the face.
The nasal bones are the underlying structure to the cartilage that forms the nose. Blunt trauma from collisions, falls and altercations can cause damage to the nasal bones. Nasal bone injury is also commonly associated with profuse bleeding, especially from the highly vascular anterior portion of the nose.
The zygomatic bones-cheekbones -form the lateral orbit and connect to the maxillary and frontal bones. The zygomatic bone forms the zygomatic arch, which is the attachment point for the masseter muscle that manipulates the mandible to allow for eating and talking.1
The frontal bone, or forehead, is the anterior bone of the skull that forms the upper portion of the orbits and nose. It is fused with the zygomatic bones, maxillary bone near the midline and the nasal bones. The frontal sinuses are in the frontal bone, which also creates the roof for ethmoid sinuses.1
Important sensory functions-vision, taste and smell-are protected and assisted by the facial bones, muscles and connective tissues. Injury to the facial bones can acutely and chronically impair those sensations.
The upper and lower sinuses are hollow cavities within several of the facial bones that are connected to the nasal cavity through short ducts to allow drainage of mucus. The sinuses are believed to assist with warming and moistening inhaled air and giving the voice resonance. Congestion in the sinuses from a cold or allergic reaction results in vocal tone changes and the sensation of sinus pressure.8
Injured facial structures can acutely or permanently impair several physiological functions. In addition to affecting sensory organs, facial trauma can compromise ventilation. The mandible and maxillary bones form the oropharynx. The nasal bones are the structure for the nasopharynx.
Patients with facial trauma (any cause) can have trouble communicating because of damage to the facial structures and/ or profuse bleeding. Communication problems can lead to decreased ability to determine the extent of injuries, collect patient history and understand the patient's mental status.
During the patient assessment, keep a high index of suspicion for the following problems in patients with known or suspected facial trauma:
- Upper airway obstruction from fluids and/or swelling
- Ventilatory compromise from damage to or obstruction of upper airway structures
- Bleeding and swelling from soft tissue injury
- Fractures and dislocations to underlying bones
- Traumatic brain injury
- Cervical spine injury.
A facial trauma patient who also had a loss of consciousness, amnesia and/or significantly altered mental status has experienced a traumatic brain injury (TBI). Remember, however, that patients can have significant facial tissue and bone trauma without having a TBI. During the initial and secondary assessment investigate for signs of TBI.
Consider the following case: A 45-year- old male fell off a ladder onto a cement floor, landed on his face and received a large gash that ran the width of his forehead and bled profusely. His frontal bone was intact with no evidence of a fracture. Bystanders reported that he did not lose consciousness, did not have altered mental status and did not have amnesia. This patient had a head wound without a TBI.
For some patients with facial trauma, there may be cervical spine injury. During the scene size-up and assessment, evaluate and clarify the mechanism of injury. Some scene clues that should raise your suspicion for facial trauma from a motor vehicle collision include:
- No seat belt use
- Ejection from the vehicle
- Cyclist or pedestrian versus vehicle
- Windshield "spidering."
For other types of mechanisms like altercations, geriatric patient falls and animal attacks, always consider facial trauma as an anticipated problem until it can be confirmed or ruled out during the patient assessment.
As with any trauma patient, complete a thorough scene size-up and begin c-spine stabilization if it is indicated. During the initial assessment, identify and begin to manage ABC life threats like absent breathing, compromised airway, absent pulse or severe bleeding. Facial injuries can cause additional life threats from airway obstruction and impaired ventilation.
Follow your local protocols for spinal motion restriction. Determine the need for hands-on c-spine stabilization based on information about the mechanism of injury. Continue hands-on stabilization until the patient is secured to a long backboard or a decision is made, based on a spinal injury assessment protocol, to discontinue c-spine stabilization.
Always consider the possibility of other problems, especially for patients injured from falls, altercations and motor vehicle collisions. The patient may have significant facial trauma with plentiful external bleeding, but that may not be his most immediate life-threatening problem. Because they are obviously visible, facial injuries can distract from other, more significant injuries. One study that looked at mandible fractures and the presence of other injuries reported that 51% of the patients had extremity trauma, 29% had thoracic trauma and 14% had abdominal trauma.5 Use a rapid trauma exam to find other significant injuries and begin treatment as indicated.
During the secondary assessment, complete a detailed head-to-toe physical exam or focused exam depending on the patient's chief complaint, mechanism and initial assessment findings. Use your senses to look, listen and feel for injuries.
Look for obvious exterior wounds like lacerations, abrasions, punctures and avulsions, as well as bruising and swelling. Blunt trauma to thin skin can cause it to simply split apart, much like a firm hit can split a very ripe melon. Control bleeding from wounds with direct pressure and dressings.
As you examine the patient's ears, nose, mouth and eyes, look for blood from wounds on the face, as well as inside the mouth and nose. A patient with lower facial trauma may have secondary wounds inside the mouth that might include tongue, gum, or cheek lacerations or avulsions. Wounds inside the mouth can cause copious amounts of bleeding that need to be spit out by the patient or frequently suctioned. Position the patient sitting upright in the lateral recovery position, or prone to assist with fluid expulsion and/or suctioning.
Carefully and systematically look through the patient's hair for additional wounds. If the facial trauma was penetrating, examine the face, head, neck, chest and back for entrance or exit wounds.
When looking at the patient's face, assess the symmetry of facial structures.9 Compare right to left. You may observe flattening, asymmetry, depressions, misalignment of the jaw or nose to the midline, or height of the eyes. Ask the patient to bring his upper and lower teeth together to look for misalignment. Look inside the mouth for loose or missing teeth.
Consider another potential scenario: A male patient was kicked in the face by a packhorse. When paramedics arrived, first responders were stabilizing the man in a supine position. The pain from his crushed face was intense, and he was intermittently crying. He had several open wounds on his face, and clear, blood-tinged fluid was observed in his outer ear canal. Although rarely seen, look for cerebrospinal fluid drainage from the ears, nose and even the eyes and mouth during the physical exam. For this patient, the fluid was from his tears.
Facial trauma patients with underlying bone damage may also have brain matter showing from an open frontal bone fracture. Oftentimes, these patients are in dire condition and may already be deceased. Follow your local protocols for treatment of traumatic cardiac arrest.
During the assessment, always listen to your patient's complaint to help find injuries. A simple statement through clenched teeth like, "That guy hit me in the jaw and now I can't move my mouth," narrows the detailed physical exam to the area of injury. A patient with a mandible fracture may make a specific complaint that his upper and lower teeth won't align correctly.10
Listen to the tone and clarity of the patient's vocalization. Slurred speech, hoarseness, stridor or other abnormal speech may be a result of facial or neck trauma. It could also be a sign of another underlying problem like stroke or intoxication.
Listen for abnormal upper airway noises like gurgling, snoring or stridor. These noises are a result of obstruction from swollen tissue, blood, blood clots, vomit, saliva, foreign bodies or damaged airway structures. Use manual or mechanical suction to remove fluids. Position patients in a recovery position with bulky padding or a vacuum mattress to assist with fluid drainage. Some airway noises, like snoring, are the result of poor airway positioning. Use a head-tilt chin-lift or jaw thrust to displace the tongue and allow for a smoother flow of air. If the patient has a fractured mandible and spinal motion restrictions are indicated, attempt a jaw thrust. A fractured jaw, depending on the fracture location, may actually be more mobile than when normal. As in other situations, if the jaw thrust is not effective, utilize a head-tilt chin-lift to achieve chest rise with ventilation, because breathing takes precedence over bone stabilization. Another alternative for an unresponsive patient is to grasp and lift his tongue to open a path to the trachea.
Treatment of stridor is cause-specific. If you're trained and authorized to do the procedure, a foreign body like food or dental structures might be removable. Swelling in the upper airway from traumatic injury is not reversible in the field. The patency of the airway may deteriorate rapidly. Follow local protocols for airway management and emergent transport.
Ask your patient about impaired vision. Is it blurry? Is he experiencing double vision? Inquire about odd sensation underneath the eyes to detect a zygomatic or maxillary fracture.9
As you palpate for injuries, listen for crepitus-the sound of bone ends or fragments moving against each other. Crepitus is not always present in facial fractures and determining its presence may be difficult due to swelling, patient pain and the type of bones injured. With the exception of the mandible, facial bones are fused to adjacent bones and otherwise fixed in place.
During the physical exam, feel for injuries by systematically palpating each of the facial bones. Start with the frontal bone then move to the orbits, bridge of the nose, cheeks, jaw bones, and then ask the patient to open his mouth. During this process, check the patient's eye tracking, pupil size and reaction, blood or fluid coming from the nose, blood or fluid in the mouth, tongue wounds and damaged teeth. Palpation may reveal deformity, depressions, step-off fractures and instability to the bones underneath intact skin.
You can also ask patients what they feel. They may have the sensation that their jaw is misaligned because their teeth don't line up as they do normally. They may also feel a variation in their breathing effort and ease due to damaged nasal cartilage and bones.
For patients with facial trauma and altered mental status, attempt to determine which came first: Did facial trauma cause a traumatic brain injury and altered mental status? Or did a stroke, intoxication, hypoglycemia, seizure or other medical problem cause the patient to fall or crash his vehicle, which then resulted in facial trauma?
As appropriate, use the secondary assessment to check the patient's blood glucose level, assess for signs of stroke, investigate seizure history, or inquire about use of toxins like drugs and alcohol.
BLS providers should follow local protocols for requesting an ALS scene response or ALS intercept during transport. Remember that the nearest ALS may be the closest hospital. At minimum, an ALS intercept is indicated for patients with facial trauma who also have:
- Airway compromise
- Ventilation compromise
- Altered mental status
- Reduced level of consciousness.
Provide initial assessment treatments as ABC life threats are found. Always following local protocols, some of those treatments may include:
- Improve airway positioning with neutral alignment, head-tilt chin-lift, jaw thrust, recovery position, and/or sitting upright.
- Insertion of airway adjuncts. Remember that because of the concern of basilar skull fracture, nasopharyngeal airways are relatively contraindicated for patients with midface trauma. Nonetheless, insertion of a nasopharyngeal airway or nasal tracheal intubation may be considered with proper insertion technique for a patient with an intact gag reflex who needs airway management for effective ventilation.11
- Visualized and nonvisualized airways are inserted based on the patient's level of consciousness, apparent injuries, and the EMS professional's training and authorization.
- Suction blood, vomit and obstructions from the upper airway. An awake and oriented patient with bleeding in his mouth may be able to self-suction his oropharynx with instruction and monitoring.
- Assisting ventilations on patients with facial trauma can be challenging if the integrity of a mask seal is compromised. One rescuer should form the mask seal while the other compresses the bag. Monitor the effectiveness of ventilations while watching for chest rise. An intra- oral mask, like the NuMask, is designed for delivering ventilations to patients with facial trauma.
- Perform bleeding control with direct pressure. For bleeding inside the mouth, an awake patient may be able to hold a gauze compress against the bleeding site. For a patient with reduced level of consciousness, use positioning and suctioning to minimize the chance of aspiration or ingestion.
- C-spine stabilization should not result in airway compromise. Ensure the patient is positioned in a way to enhance airway management. This might be spinal motion restriction in the lateral recovery position using bulky padding or a vacuum mattress.
Lower facial trauma to mandible and maxillary bones can make maintaining a mask seal to deliver ventilations difficult to impossible. Inability to deliver effective ventilations when needed is a life-threatening emergency. Consider all options to secure the patient's airway with a nonvisualized, visualized or surgical airway. Endotracheal intubation may be difficult or impossible because of copious bleeding and/or damage to airway insertion landmarks. Inflation of the proximal cuff may be ineffective at securing a non-visualized airway if the patient has significant maxillary damage. Anticipate airway management challenges for any patient with significant lower facial trauma.
Problems that are non-life-threatening are typically tissue trauma and bone fractures. Apply hemostatic powders or dressings based on your training, authorization and indications. Apply dressings and bandages to cover facial wounds. Unlike other musculoskeletal injuries, splinting options for unstable facial bones are limited. The patient may be hand-stabilizing his jaw. A circumferential dressing under the lower jaw and over the top of the head can be used to stabilize a mandible fracture. Helping the patient minimize movement and being conscious of the injury during spinal motion restriction procedures are helpful to minimize pain.
For pain management, apply ice to isolated traumatic injuries like a black eye or broken nose. ALS providers should follow their local protocols for pharmacological pain management. Reassess the patient's vital signs and pain level after any pain management interventions.
Follow local triage criteria to identify major trauma patients and preferentially transport them to the highest level of trauma care available in your city or region. Some patients may not meet the trauma criteria, but may be candidates for transport to specialty hospitals due to burns or extensive wounds that might require the services of a plastic surgeon. As needed, consult with online medical control to determine the best destination for facial trauma patients.
As discussed earlier, facial trauma, especially to the upper face, can be a sign of intimate-partner violence-a type of physical abuse. Facial trauma injuries to pediatric and geriatric patients that are not consistent with the reported mechanism can also be indications of physical abuse. In the United States, EMS professionals must report suspected or confirmed abuse to the receiving facility nurse or physician, and/or law enforcement.
Animal bites to the face are most often from dogs2 and are high risk for infection. For transport services with extended transport times, consider beginning wound irrigation and cleaning during transport if trained and authorized. Most important, attempt to determine the rabies vaccination status of the animal while not endangering yourself or others. Follow local protocols for reporting animal bites to public health and law enforcement officials.
Motorcycle, ATV and snow machine riders may have significant facial trauma as a result of a collision or ejection. Helmet removal should be based on need to manage the patient's airway and ability to stabilize the patient's spine after removal.
Because of the potential for obstruction from fluid in the upper airway, not all patients are well-suited for supine stabilization. Consider applying spinal motion restriction to patients in the lateral position when their airway will require frequent suctioning.
The most common impaled objects we have seen in patient's faces are fish hooks. Dramatic penetrating impaled objects into the face and upper airway are relatively rare. Most are in the dermis or epidermis and only require simple stabilization. If an impaled object is causing airway compromise, follow local protocols to remove it. Otherwise, stabilize impaled objects to prevent further injury during transport.
Facial trauma can cause significant emotional distress in patients and their parents, spouses or others. If they ask, honestly describe to them the size, depth and extent of their wounds. Patients with facial trauma cannot self-examine the extent of their wounds. If they express concern about the potential and severity of scarring secondary to facial trauma, reassure them that physicians will examine their wounds and suggest treatment options.
Facial trauma is most frequently caused by motor vehicle collisions, physical altercations and falls. Assess for and treat ABC life threats due to facial trauma while remembering life threats may also come from injury to other body systems. Maintaining an open airway is the most significant treatment challenge. Consider all airway management tools and be prepared to use multiple techniques. Follow trauma patient triage and transport guidelines to deliver the patient to the most appropriate level of trauma care.
Fractures and Associated Symptoms
|Pain, tenderness, bruising and deformity are symptoms that are generic to most fractures. Some facial fractures have associated symptoms that are specific to the fracture.9|
|Clear nasal discharge|
|Jaw||Inability to align lower and upper teeth|
|Bruising under the tongue|
|Maxillary||Inability to align lower and upper teeth|
|Clear nasal discharge|
|Altered sensation beneath eye|
|Pain from jaw motion|
|Altered sensation beneath eye|
To learn more about injuries and illness related to facial trauma, visit RapidCE.com and take CECBEMS-approved CE lessons on topics like traumatic brain injury, stroke, diabetes, c-spine injuries in athletics, geriatric patient assessment, kinematics of trauma, nosebleeds and musculoskeletal injury.
CONTINUING EDUCATION FROM EMS MAGAZINE
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3. Dev V. Facial trauma: Nasal fractures. http://emedicine.medscape.com/article/1283709-overview.
4. Cohen A. Facial trauma. Zygomatic arch fractures. www.theartofeyes.com/linked%pdf%20documents/Medical%20Texts%20&%20Papers/Facial%20Trauma_Zygomatic%Arch%20Fractures.pdf.
5. Laub D. Facial trauma: Mandibular fractures. http://emedicine.medscape.com/article/1283150-overview.
6. Arosarena OA, Fritsch TA, Hsueh Y, et al. Maxillofacial injuries and violence against women. Archive of Facial Plastic Surgery 1:48-52, Jan-Feb 2009.
7. Atlas of Human Anatomy. Cobham Surrey: Taj Books, 2002.
8. Senisi Scot A, Fong E. Functional Anatomy for Emergency Medical Services. Clifton Park, NY: Delmar Thomson Learning, 2002.
9. Lawe D, Nathan M. Fracial fracture. http://emedicinehealth.com/facial_fracture/article_em.htm.
10. Salomone JP, Pons PT. PHTLS: Prehospital Trauma Life Support, 6th Ed. St. Louis, MO: Mosby Elsevier, 2007.
11. Pierre E, McNeer R, Shamir M. Early management of the traumatized airway. Anesthesiology Clinics 25:1-11, 2007.
Greg Friese, MS, NREMT-P, is an e-learning designer, podcaster, author, presenter and paramedic. He is also a lead instructor for Wilderness Medical Associates. Read more from him at the EverydayEMSTips.com blog. Connect with Greg at EMSUnited.com, Facebook.com/gfriese or twitter.com/gfriese.
Kevin T. Collopy, BA, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also a flight paramedic for Spirit Ministry Medical Transportation in central Wisconsin and a lead instructor for Wilderness Medical Associates. Contact him at firstname.lastname@example.org.