Facial trauma can present some of the most challenging injuries that prehospital care providers are called on to manage. Although most injuries to the face aren’t life-threatening, some may compromise the patient’s airway or result in significant hemorrhage requiring the provider’s immediate attention.
Facial trauma may also be associated with other injuries that place the patient’s life in jeopardy. Finally, these injuries may be disfiguring, which may distract the novice provider from recognizing and addressing more serious conditions.
Mechanisms of Injury
Although injuries to the face are mostly the result of blunt trauma, they may also result from penetrating trauma. The most common causes of blunt trauma to the face are motor vehicle crashes and assaults. During a crash, an occupant may strike their face on hard surfaces inside the vehicle, such as the steering wheel, dashboard or windshield, or on the roadway if they’re ejected from the vehicle.
Assaults, another common cause of injuries, occur when the face is punched by a fist or struck by an object. A minority of these injuries result from stab, gunshot or shotgun wounds.
Assessment: Primary Survey
The primary survey is a rapid assessment of vital functions to identify life-threatening conditions. The typical approach for performing the primary survey is through the standard ABCs—airway, breathing and circulation—disability and exposure (A-B-C-D-E).
Airway & breathing: The primary survey begins with an assessment of airway patency. When the provider first sees the patient, numerous clues may point toward an inadequate airway. When lying in a supine position, an unconscious patient is at risk for airway obstruction from the tongue as it relaxes and falls back to block the airway. Noisy breathing, namely gurgling or high-pitched noises, indicates partial airway obstruction. The airway may be compromised by broken or avulsed teeth and fragments of bone, as well as blood or vomit. Because the tongue is attached to the mandible, fractures of that bone may predispose the tongue to block the airway, especially if it’s broken in two locations.
Facial fractures, such as injuries to the maxilla or mandible, may cause mechanical obstruction or result in associated hemorrhage. Penetrating injuries, such as those caused by a gunshot wound to the face, and severe facial fractures may disrupt blood vessels deep within the facial skeleton, resulting in hemorrhage that may pool in the airway. This blood may drain externally through the nose and mouth, but it may also be swallowed by an unconscious patient. Injuries to the arteries of the face can produce an expanding hematoma that may grow to occlude the airway. Nasal flaring and the use of accessory respiratory muscles, such as the strap muscles of the neck, indicate the patient is struggling to breathe.
Conscious patients with facial injuries will typically find a position that facilitates breathing (often sitting up and leaning forward), and they may become combative if forced to lay supine. With the exception of airway compromise, facial trauma doesn’t impair oxygenation and ventilation (breathing). Thus, when a patient with facial trauma is noted to have difficulty in breathing but has an apparently patent airway, the provider should suspect either an occult airway obstruction (i.e., one they have not yet identified) or an associated thoracic injury, such as a pulmonary contusion or pneumothorax.
Circulation: The face and scalp possess a high concentration of blood vessels, and even a small wound can produce dramatic hemorrhage. More serious wounds can result in life-threatening hemorrhage. A degloving injury of the scalp, in which a large portion of tissue is peeled back off the skull, may result in significant external hemorrhage and decompensated hypovolemic shock. As noted above, severe fractures to the midface may result in exsanguinating hemorrhage.
Disability: Trauma to the face may be associated with traumatic brain injuries and injuries to the spine and spinal cord. In the primary survey, the provider should assess the patient’s Glasgow Coma Scale (GCS) score, making note of the eye, verbal and motor components. If the patient’s GCS score isn’t normal (i.e., less than 15), the provider next assesses the pupils for symmetry and reaction to light. A depressed GCS score, combined with a unilateral dilated pupil and lateralizing signs (weakness on one side of the body), is highly suggestive of an intracranial hematoma (subdural or epidural). As with other vital signs, the GCS score should be reassessed at five- to 15-minute intervals, depending on the severity of injury.
Exposure: In this step, all clothing is removed to allow for assessment of any other life-threatening conditions that have yet to be noticed. Hats or caps should be removed from the head so the entire scalp can be visualized and palpated.
Consider removing any protective gear (e.g., sports or motorcycle helmets) that may preclude a thorough assessment of facial injuries.
Assessment: Secondary Survey
The secondary survey is a complete head-to-toe assessment of the patient performed to identify all obvious injuries. It’s performed only after the primary survey is complete and any life-threatening conditions have been ruled out or corrected. Conscious patients may also be questioned about their injuries, including the mechanism of injury. Other important symptoms to note include new onset of visual changes, double vision, hearing impairment or numbness, location of pain, inability to open or close the mouth and a change in the alignment of teeth (malocclusion).
The provider should inspect and palpate the face of all patients who have suffered facial trauma. The face is inspected for any soft-tissue injuries. Any deviation of the nose or asymmetry of facial structures, such as cheek bones and the mandible, is noted. The oropharynx should be examined for evidence of broken teeth, foreign material or swelling of the palate or floor of the mouth. Clear fluid draining from the nose or ear canals may be cerebrospinal fluid and indicate a basilar skull fracture. The face is gently palpated, looking for sites of tenderness, bony step-offs or crepitation.
In unconscious patients, a gloved flinger can be inserted into the mouth and the maxilla gently pulled forward, looking for instability of the bones of the midface.
Extraocular movements can be tested by having the patient track a finger moving in different directions. Deficits in EOMs may be the result of a nerve injury or entrapment of one of the muscles that move the eye. The trigeminal nerves can be tested by lightly stroking the forehead, cheek and mandible and having the patient report any decreased sensation. The branches of the facial nerve can be tested by asking the patient to sequentially wrinkle their forehead, raise their eyebrows, close their eyes tightly, puff out their cheeks, frown and smile, showing their teeth.
Soft-tissue injuries of the face may include contusions, hematomas, abrasions, lacerations and avulsions, as well as stab and gunshot wounds. Because of the plentiful blood supply, wounds that break the skin are often associated with hemorrhage, which is often brisk but rarely fatal. Although many of these wounds are limited to the skin and subcutaneous fat, deeper wounds may damage underlying structures, including muscles, nerves and salivary glands. Soft-tissue injuries that overlie deformities and points of tenderness or crepitation may represent open fractures of the facial skeleton.
The nasal bones are the most commonly fractured facial bones. Signs of a nasal fracture include swelling, deformity and tenderness of the nose. Nasal bone fractures may be associated with copious epistaxis (i.e., nosebleed). However, this bleeding is generally self-limited. Squeezing of the nostrils just below the end of the nasal bones can assist with controlling persistent epistaxis.
One concerning complication of a nasal fracture is a septal hematoma—a collection of blood inside the nasal septum. The blood supply to the delicate, cartilaginous portion of the nasal septum may be impaired by the hematoma, resulting in necrosis of the cartilage. Over time, this cartilage collapses, and the nose develops a “saddle deformity.”
Another type of fracture is an orbital “blowout” fracture, which involves a direct blow to the orbit. As the pressure in the orbit increases, the medial wall or floor may rupture, allowing orbital contents, including fatty tissue and muscles, to herniate outward. A common fracture pattern involves rupture of the orbital floor, resulting in entrapment of the inferior rectus muscle of the eye. This prevents the affected eye from looking superiorly when EOMs are examined. Because the eyes don’t move in unison, the patient may complain of diploplia when looking in certain directions.
Another sign of a blowout fracture is enophthalmos, or sinking in of the eyeball in orbit, although it’s often hard to appreciate in an acute injury. An orbital fracture may also be associated with proptosis, or protrusion of the eyeball from its socket. Proptosis usually results from a retrobulbar hematoma, a collection of blood behind the eyeball, and may jeopardize sight by stretching the optic nerve.
Yet another type of facial fracture is to the zygomatic arch, or cheekbone. On each side of the face, the zygomatic bone creates an arch where it connects to the temporal bone on the side of the skull. This zygomatic arch provides structure to the cheek and is prone to fracture when struck by a direct blow. Signs of a cheekbone fracture include swelling; bruising; facial asymmetry, which is characterized by a depressed cheekbone on the injured side; and trismus, or spasm of the muscles of mastication that impairs the ability to open the mouth.
For other types of fractures occurring to the bones of the midface, we can look to history. More than a century ago, Rene LeFort studied facial fractures in an experimental fashion. He noted three common patters of fractures involving the bones of the midface1 (see Figure 2,). The following are called LeFort fractures:
- LeFort I: This injury involves a horizontal fracture of the maxilla from the remainder of the midface. The maxilla may be depressed downward toward the tongue and compromise the airway because of the fracture and associated swelling.
- LeFort II: This injury is also known as a pyramidal fracture because the fracture plane extends obliquely in an inferolateral direction. This type of midface fracture may be associated with significant hemorrhage because the fracture extends through the highly vascularized sinus cavities.
LeFort III: This injury is also known as craniofacial dissociation because the bones of the midface are fractured off from the remainder of the skull.
Fractures of the mandible are the second most common type of facial bone fracture. If conscious, the patient often complains of jaw pain—especially when clenching their teeth—and malocclusion. Malocclusion refers to a change in how the teeth come together with the mouth. Signs of a mandibular fracture include tenderness, swelling and deformity of the mandible. When examining the oral cavity, the provider might note tears in the mucosa of the gums and broken teeth.
Midface fractures often don’t fit perfectly into one of the three LeFort categories but may be a combination of two types. These fractures can be suspected in an unconscious patient by mobility, which can be noted when a gloved finger is inserted into the mouth and the hard palate is gently pulled forward.
Finally, injuries to teeth are common in patients with facial trauma. The provider may note that teeth are loosened, fractured or avulsed (knocked out) from their sockets. Fractured teeth are often painful, and the pain may worsen when the tooth is exposed to air. Tooth fragments and avulsed teeth may be found in the oral cavity and should be removed. Avulsed teeth may be salvaged if re-implanted within a short time period. Table 1 (p. 54) describes the care of avulsed teeth.
Like most other injuries, definitive diagnosis and management occur in the hospital setting. In the prehospital setting, place emphasis on establishing and maintaining a patent airway and controlling external hemorrhage. These actions can be lifesaving.(2)
When caring for a patient with facial trauma, the provider’s highest priority is to ensure a patent airway. Some conscious patients with severe facial trauma may be able to successfully manage their airway. Although potential spinal injury is a concern, these patients may become combative if forced to wear a C-collar or lie supine on a long backboard. Such patients can be transported in a position of comfort, generally sitting up, and they may be given a suction device and allowed to suction fluid from their airway as needed. If the patient allows, use manual stabilization of the head and neck during transport.
For the unconscious patient, essential airway skills are initiated while another provider applies manual stabilization of the head and neck. The mouth may be opened with a modified jaw thrust maneuver. Teeth and regurgitated food particles are swept from the mouth and suctioning is used to remove blood. If transport times are brief, the airway may be successfully managed with insertion of an oral airway and ventilating via a bag-valve-mask (BVM) device. Repeat suctioning is performed as needed.
For longer transport times, the airway is placed or endotracheal intubation is performed. Use of a BVM may fail to ventilate a patient with severe facial trauma because an adequate seal may not be possible with severe soft-tissue injuries that involve the mouth. If you can’t ventilate via either approach, consider performing needle cricothyrotomy with transtracheal ventilation or a surgical cricothyrotomy, if protocols allow.
The airway should be reassessed at frequent intervals because facial traumas may have occult airway injuries or progressively develop an airway obstruction. They may also have associated thoracic injuries that can also contribute to impaired oxygenation and ventilation. Use pulse oxymetry (SpO2) and administer oxygen to maintain oxygenation at or above 95%.
Another priority is to maintain circulation. These patients with facial trauma frequently experience external hemorrhage. Most bleeding from facial injuries can be controlled with firm, direct pressure on the site of the bleeding. Extensive scalp bleeding may be controlled with the application of a pressure dressing, created out of gauze sponges and an elastic bandage. If protocols allow, use of a topical hemostatic agent may help slow vigorous hemorrhage. Unlike with bleeding from the extremities, tourniquets aren’t used around the neck because tightening will result in impaired blood flow to the brain. (For more on caring for hemorrhaging patients, see the continuing education article, “Shock Sense,” JEMS June 2011 issue,p. 58)
If bleeding continues from the oropharynx after intubation or cricothyrotomy is performed, the mouth can be gently packed with gauze from a roll. This may help tamponade bleeding from the mouth. If significant bleeding is coming from the nasal openings (nares), packing these may only result in blood pooling in the hypopharynx.
If signs of shock are present, IV volume resuscitation can be initiated. Titrate IV fluids should to maintain a systolic blood pressure in the 80–90 mmHg range. More aggressive volume resuscitation with crystalloid solutions may worsen hemorrhage by disrupting blood clots or diluting blood clotting factors. Transport must never be delayed simply to place IV lines; IVs can be initiated during transport.
If transport is prolonged due to long distances to a medical facility, wounds can be irrigated with saline. Gently brush dirt and other debris from a wound using a moistened gauze pad.
Because many patients with significant facial injuries have concomitant traumatic brain injuries (TBIs), frequently reassess neurologic functioning (GCS score and pupillary response). Avoid hypoxia and hypotension because these factors are known to worsen the outcomes of patients with TBIs. Anemia can also contribute to secondary brain injury, underscoring the need to control external hemorrhage.
Finally, although more minor facial injuries can be satisfactorily managed at most community hospitals, definitive management of complex facial trauma often requires the skills of numerous surgical specialties, including plastic surgery, maxillofacial surgery, otorhinolaryngology and ophthalmology. Therefore, these patients are probably best managed in Level I and II trauma centers.
Many victims of severe facial trauma may recover with cosmetically satisfying results because of the modern techniques of operative fixation and the use of bone grafts. The prehospital care provider should focus on ensuring a patent airway and controlling hemorrhage and then transporting to a facility capable of managing the patient’s injuries. Some facial injuries may appear gruesome, but the provider should not be distracted from identifying and managing life-threatening conditions. JEMS
Acknowledgment: The author would like to thank Vincent J. Perciaccante, DDS, for his insightful review of the manuscript.
1. LeFort R: Etude experimentale surgery les fractures de la marclioire superieure, Parts I, II , III. Paris, 1901. Rev Chir.
2. Salomone JP, Pons PT, McSwain NE, et al, Eds.: Prehospital Trauma Life Support. 7th Edition. St. Louis: Elsevier, 2011.
>> Seyfer AE, Hansen JE. Facial Trauma. In: Moore EE, Feliciano DV, Mattox KL, Eds: Trauma. 5th Edition. New York: McGraw Hill, 2003.
A provider called to treat a patient with a facial injury must understand the anatomy of the face. A number of bones fuse together to form the facial skeleton (see Figure 1,). The forehead is supported by the broad fontal bone, the lower portion of which forms the superior aspect, or roof, of the orbit (eye socket). Two maxillary bones comprise much of the midface’s support. A small pair of nasal bones attaches superiorly to the frontal bone and laterally to the maxillary bones, providing structure to the nose. The zygomatic bones, or zygoma, lie between the maxillary bones and the temporal bone of the skull, supporting the cheeks. Portions of the maxilla and the zygoma form the inferior aspect (or floor) of the orbit. The frontal bone and each maxilla contain hollow cavities, the frontal and maxillary sinuses. The arch-shaped mandible provides structure to the jaw. Additional bones form the deep, internal structure of the face.
The structures of the head are highly vascularized, providing a rich blood supply to the facial tissue and nerves. On each side of the neck, the common carotid arteries travel from the thorax up toward the head. Near the angle of the jaw, each carotid artery bifurcates (divides) into the internal and external branches. The internal carotid artery then travels deep in the head and enters the cranial vault to supply blood to the brain.
The external carotid artery has numerous branches that supply blood to the face and scalp. They are the occipital artery, which supplies the occipital scalp; the posterior auricular artery, which supplies the ear and adjacent scalp; the lingual artery, which supplies the tongue and the floor of the mouth; the facial artery, the chief artery of the face; and the two terminal branches of the vessel, the maxillary artery and superficial temporal artery.
Each facial artery crosses over the mandible near its angle and then traverses superomedially across the face toward the medial corner of the eye. The maxillary arteries have many branches that supply the deep structures on the sides of the face. The superficial temporal arteries emerge from behind the parotid gland—the large salivary glands located over the angle of the mandible—and track superiorly just anterior to the ear, supplying the superior portion of the scalp. Because there are many interconnections between these arteries, wounds to the face often result in copious hemorrhage.
Virtually all the important facial nerves arise from the cranial nerves, which are paired nerves that originate directly from the base of the brain. The optic nerves (cranial nerve II) connect the light-sensing retina of the eye to the brain. Cranial nerves (CNs) III, IV and VI control the muscles that move the eye. The movement of each eye comes from six muscles: the superior oblique; the inferior oblique; and the superior, inferior, medial and lateral rectus muscles. The trochlear nerves (CN IV) innervate the superior oblique muscles, and the abducens nerves (CN VI) stimulate the lateral rectus muscles. The oculomotor nerves (CN III) innervate the superior, inferior and medial rectus muscles and the inferior oblique muscles, and control pupillary dilation. Injury to any of these nerves or muscles will impair extraocular movements (EOMs) and result in binocular diploplia (double vision when looking out both eyes) and disconjugate gaze (eyes pointing in different directions).
Sensation of the face comes from the trigeminal nerves (CN V), each of which split into three branches. The ophthalmic nerves (often abbreviated V1) provide sensation to the upper eyelid and the forehead. The maxillary nerves (V2) provide sensation to the midface, from the lower eyelid to the upper lip. The mandibular nerves (V3) provide sensation from the ear down across to the lower lip and jaw. The mandibular nerve also controls the muscles of mastication (chewing). The facial nerves (CN VII) supply the platysma (a superficial muscle in the neck), as well as the muscles of facial expression. As the facial nerves pass through the parotid gland, they divide into five branches: temporal, zygomatic, buccal, mandibular and cervical. Injury to any of these branches results in an inability to move the muscles they innervate.
This article originally appeared in April 2011 JEMS as “The Face of Trauma: Assessment & management of facial trauma injuries.”