Face injury

Consider three life-threatening emergencies from facial trauma:

Airway obstruction
- When to expect
  - Comminuted fractures of upper and lower jaws
  - Injuries that result in swelling or bleeding into the airway spaces
- Signs
  - Stridor
  - Hoarseness
  - Inability to manage secretions
- Management
  - Early consideration intubation
Haemorrhage
- Facial lacerations
  - Usually due to transected major arteries
  - Needs to be ligated - will generally continue to bleed until effectively manually controlled
  - Be careful of adjacent nerves
- Closed fractures/sinus injuries/midface injuries
  - Mostly just needs manual repositioning of maxilla/zygoma combined with anteroposterior nasal packing
  - If it continues to bleed, needs angioembolisation
Aspiration
- Often accompanies fractures of the middle and lower face, especially with cerebral injury or depressed mental status
- Need to intubate early

Exam

Bruising/contusions
Crepitus
Pain
Localised tenderness
Numbness/paralysis
Malocclusion
Diplopia
VA loss
Facial asymmetry
Changes in eye position and facial contour

Orbital compartment syndrome

Pathophys
- Susceptible to compartment syndrome due to small size and bony walls
- Bleeding into retrobulbar, subperiosteal, extraconal, and/or intraconal spaces of the orbit can cause rapid orbital distention
- Ischaemia of the orbital tissue can result, leading to damage and permanent vision loss
- Big fractures are protective due to allowing decompression
Presentation
- Proptosis and taut orbital content, or increased resistance to retropulsion, are always present
- Mild compartment syndrome won't have vision changes or signs of optic nerve compromise
- Intraocular pressure >40mmHg a lateral canthotomy and cantholysis is indicated
Technique
- Prep and drape
- Anaesthetise with 2% lignocaine with adrenaline in the lateral canthus - infiltrate subcutaneously but don't puncture globe
- Put an artery clamp over the lateral canthus horizontally and leave for one minute to reduce bleeding
- Take scissors with one blade on the skin side and one blade on the conjunctival side and cut the lateral corner of the eyelid while applying lateral pressure. Incise as far as orbital rim
- The inferior crus of the lateral canthal tendon will need to be cut to release the lower eyelid from the lateral orbital wall - use the scissors held directly laterally to strum the inferior tendon inside the cut canthotomy wound, which feels like a firm, tense cord. Now open the blades of the scissors and cut the cordlike structure until the lower eyelid becomes freely mobile, which is again about as far as the edge of globe.
- Haemostasis will come with pressure or diathermy.