Key Points

• The ABCs of trauma include airway, breathing, circulation, and cervical spine clearance.

• Laryngeal and pharyngoesophageal injuries must be suspected in blunt or penetrating neck injuries.

• Intravenous access should be established and volume replacement initiated quickly.

• Isolated facial injuries can result in significant bleeding and can be associated with orbital or central nervous system injury.

• Overlooked facial fractures can result in long-term functional and cosmetic defects.

The ABCs of trauma should be remembered when treating a patient with cervicofacial trauma. This includes evaluation and treatment of airway, breathing, circulation, and cervical spine. The most pressing issue after significant face, head, or neck trauma is the potential for respiratory compromise, secondary to several causes. Altered mental status can lead to aspiration of blood or secretions with or without central hypoventilation. Comminuted facial fractures (midface or mandibular) can distort the oral and pharyngeal airway sufficiently to cause obstruction. An undetected expanding pharyngeal or neck hematoma can cause airway obstruction by extrinsic compression of the trachea or pharynx. Blunt or penetrating neck injuries can cause laryngeal fracture, bleeding, or hematoma, leading to critical airway obstruction.

Potential airway obstruction must be addressed quickly because complete obstruction can progress rapidly. The diagnosis is clinical because hypoxemia and carbon dioxide retention are late signs. Extensive facial edema or ecchymosis should arouse concern for facial fracture. A muffled voice can be the result of expanding hematoma. Laryngeal or tracheal injury should be suspected if the patient has a change in the voice, hemoptysis, subcutaneous emphysema, or stridor.

Stabilization of a compromised airway should be accomplished as soon as possible. Endotracheal intubation may be attempted, with plans for emergent cricothyrotomy as necessary. If time permits, the on-call anesthesiologist, trauma surgeon, or otorhinolaryngologist should be consulted to assist in airway management. Blind intubation (especially nasotracheal) or insertion of a laryngeal mask airway (LMA) is not recommended because this further compromises the already tenuous airway if intubation is unsuccessful. Although tracheotomy is the preferred procedure when endotracheal intubation is impossible or contraindicated, cricothyrotomy is also acceptable and can be lifesaving.

There is potential for significant blood loss after severe head and neck trauma. Intravenous access should be established and volume replacement initiated quickly. Bleeding from facial wounds can be controlled with direct pressure and suture ligation of arterial bleeding. Management of epistaxis is discussed earlier. Bleeding from the neck, or evidence of expanding hematoma, implies a major vessel injury and requires immediate operative exploration by a trauma surgeon, vascular surgeon, or otorhinolaryngologist.

Unrecognized pharyngeal and esophageal injury can result in life-threatening infection. These injuries might not be obvious on initial evaluation and require a very high index of suspicion. Contrast studies and endoscopy are usually required to confirm the diagnosis. Treatment can include repair of the injury or external drainage to allow healing.

Isolated facial injuries are rarely life threatening but still can result in significant bleeding and, rarely, airway compromise and permanent disability. Significant facial trauma should be evaluated in the ED. The potential for intracranial and cervical spine injuries should be considered when major facial injuries are present. Trauma of the periorbital region requires ophthalmologic evaluation. All lacerations should be inspected, cleaned, and sutured. Antibiotics should be used if contamination is likely.

Deeper injuries can result in facial nerve transection. If facial nerve weakness is detected, plastic surgery or ENT consultation is necessary for expedient nerve exploration and repair. The parotid salivary duct can also be injured and requires repair over a stent. Facial fractures should be evaluated with CT (both axial and coronal images). Possible mandibular fractures should be evaluated with plain x-ray films, including panographic (Panorex) films. Overlooked and untreated facial fractures can result in significant long-term functional and cosmetic deficits. Oral surgery consultation is sometimes required, especially with injury to the teeth or altered dental occlusion.

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