Rosen & Barkin's 5-Minute Emergency Medicine Consult (262 page)

Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult

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DIAGNOSIS TESTS & NTERPRETATION
Lab

Indicated for evaluation of associated injuries or if needed for preoperative reasons.

Imaging

Facial bone CT scanning with reconstructions is the imaging modality of choice for suspected facial injuries.
Plain films such as a Waters view are less helpful.
- May show fractures, asymmetry, or blood in the sinuses, or the classic teardrop opacity in the maxillary sinus representing an orbital floor blow-out fracture.
Jug-handle views (submental vertex) may visualize zygomatic arch fractures.

DIFFERENTIAL DIAGNOSIS

Nasal fracture.
Zygoma fractures (arch or tripod fracture).
Le Fort fracture.
Skull fractures including frontal sinus fractures and cribriform plate fractures.
Nasofrontoethmoid complex fractures.
Mandibular fractures.
Orbital fracture including blow-out fracture
Associated injuries to teeth, neck, and brain.
Contusions or lacerations without underlying fractures.

TREATMENT
PRE HOSPITAL

ALERT

INITIAL STABILIZATION/THERAPY

Aggressively manage airway if not patent, patient requires airway protection, or ongoing swelling or bleeding threatens airway. RSI is initial airway management of choice in facial injuries; use etomidate or midazolam and vecuronium, rocuronium, or succinylcholine for RSI.
Surgical airway (cricothyroidotomy or needle cricothyroidotomy) may be required if RSI is unsuccessful.
Nasotracheal intubation is contraindicated in most facial fractures.
Protect cervical spine until clinically or radiographically cleared.
Once airway is secure, other major injuries take precedence over facial injuries.
Bleeding may be difficult to control and may require posterior packing if direct pressure does not work.

ED TREATMENT/PROCEDURES

Consult ear, nose, throat specialist; plastic surgery; or oral surgery for complex fractures, including all Le Fort fractures, and neurosurgery for frontal sinus fractures involving the posterior table.
Antibiotics (cefazolin or clindamycin in penicillin-allergic patients) for open fractures and CSF leak.
Tetanus prophylaxis.
Parenteral pain medication (morphine or fentanyl).
A septal hematoma must be drained in the ED:
- Anesthetize, aspirate with an 18G–20G needle, and pack both nares with Vaseline gauze.
- Discharge on amoxicillin or erythromycin with recheck in 24 hr by ear, nose, and throat specialist.
Nondisplaced zygomatic fractures can be discharged with analgesics (acetaminophen or ibuprofen); refer displaced zygoma and tripod fractures that are otherwise stable for outpatient reduction in 2–3 days after swelling is reduced.
Overlying lacerations with simple fractures can be sutured in the emergency department; if patient is discharged, treat with amoxicillin or azithromycin.
Patients discharged with facial fractures with blood in the sinus should be treated with amoxicillin or azithromycin.

Pediatric Considerations

Surgical cricothyroidotomy should not be performed in children younger than 8 yr:
- Needle cricothyroidotomy with jet ventilation may be performed.
Children are at high risk of associated injuries.
Repair of facial fractures should not be delayed more than 3–4 days (rapid healing of facial fractures and the risk of malunion and cosmetic deformity).

MEDICATION

Acetaminophen: 500 mg (peds: 10–15 mg/kg, do not exceed 5 doses/24 h) PO q4–6h, do not exceed 4 g/24 h
Amoxicillin: 250 mg (peds: 40–80 mg/kg/24 h) PO q8h
Azithromycin: 500 mg PO day 1 followed by 250 mg PO days 2–4 (peds: 10 mg/kg PO day 1 followed by 5 mg/kg days 2–4)
Cefazolin: 1 g (peds: 50–100 mg/kg/24 h) IV or IM
Clindamycin: 600–900 mg (peds: 25–40 mg/kg/24 h) PO q8h
Diazepam: 5–10 mg (peds: 0.1–0.2 mg/kg) IV
Etomidate: 0.2–0.3 mg/kg (peds: 0.2–0.3 mg/kg) IV (not recommended in children <10 yr)
Fentanyl: 2–10 μg/kg (peds: 2–3 μg/kg) IV
Ibuprofen: 600–800 mg (peds: 20–40 mg/kg/24 h) PO TID–QID
Ketamine: 1–2 mg/kg (peds: 1–2 mg/kg) IV
Midazolam: 2–5 mg (peds: 0.02–0.05 mg/kg per dose, max. dose 0.4 mg/kg total and not >10 mg) IV over 2–3 min
Morphine sulfate: 0.1–0.2 mg/kg (peds: 0.1–0.2 mg/kg) IV q1–4h titrated
Rocuronium: 0.6–1.2 mg/kg (peds: 0.6 mg/kg) IV
Succinylcholine: 1–1.5 mg/kg (peds: 1–2 mg/kg) IV
Vecuronium: 0.1–0.3 mg/kg (peds: 0.1–0.3 mg/kg) IV

FOLLOW-UP
DISPOSITION
Admission Criteria

Discharge Criteria

No evidence of significant head, neck, or other injuries.
Closed fractures of the zygoma, orbit, sinus, or anterior table of the frontal sinus with appropriate follow-up in 24–36 hr.
Septal hematomas that have been drained in the emergency department require follow-up in 24 hr.
Refer displaced zygoma and tripod fractures that are otherwise stable for outpatient reduction in 2–3 days after swelling is reduced.

Issues for Referral

ENT, plastic surgery, or neurosurgery may all handle facial fractures, actual referral depends on practice patterns at your institution. If there is no CSF leak or involvement of the posterior table of the frontal sinus, it is reasonable to initially consult ENT.

PEARLS AND PITFALLS

Facial fractures and injuries can be very dramatic in appearance.
- Airway management always takes precedence. Avoid nasotracheal intubation.
- After the airway is secured as necessary, evaluation of other injuries takes precedence—do not miss life-threatening injuries.
  - Cervical spine.
  - Pulmonary or thoracic.
  - Intra-abdominal injuries.
Have a low threshold for obtaining facial bone CT for evaluation of facial injuries.
Facial fractures are frequently associated with ocular injuries. Perform a thorough eye exam.
Always assess for a nasal septal hematoma.
Missing teeth must be accounted for, obtain a CXR to rule out aspiration.

ADDITIONAL READING

Chapman VM, Fenton LZ, Gao D, et al. Facial fractures in children: Unique patterns of injury observed by computed tomography.
J Comput Assist Tomogr.
2009;33(1):70–72.
Cole P, Kaufman Y, Hollier L. Principles of facial trauma: Orbital fracture management.
J Craniofac Surg.
2009;20(1):101–104.
Grunwaldt L, Smith DM, Zuckerbraun NS, et al. Pediatric facial fractures: Demographics, injury patterns, and associated injuries in 772 consecutive patients.
Plast Reconstr Surg.
2011;128(6):1263–1271.
Kontio R, Lindqvist C. Management of orbital fractures.
Oral Maxillofac Surg Clin North Am.
2009;21(2):209–220.
Sharabi SE, Koshy JC, Thornton JF, et al. Facial fractures.
Plast Reconstr Surg.
2011;127(2):25e–34e.