Ambulance

Clinical Focus on Transferring Facial Injuries
Facial injuries - how safe
are they to transfer? By Mr Mike Perry
Facial injuries present a broad spectrum, from the relatively insignificant, to those that are potentially
life and sight-threatening. Very often their appearances can be deceptive and their management difficult,
especially in those patients that need to be transferred on a spine board. By their very nature, patients
with significant injuries will often want to sit upright and lean forwards - a natural protective response
which helps keep the airway clear. This of course goes against our current wisdom of transferring patients
supine in order to protect the torso and spine. If we add to this the frequent association of alcohol
intoxication, head injuries and a full stomach, how best to stabilise and transfer these patients can
sometimes be very difficult. However the good news, is that in most cases patients can be safely managed
using a simple triage process and possession of a few skills. The key message is that…
Although very dramatic in appearance
most facial injuries do not require urgent or
complex intervention - so long as the airway
is secure and there is no active bleeding.
reported causes of injuries included
assaults, falls (especially in children and the
eldery), sporting injuries and motor vehicle
collisions. The nasal bones are perhaps the
commonest facial fracture, followed by
mandibular and zygomatic (cheek) fractures.
Soft tissue lacerations are also common,
either in isolation, or associated with
underlying fractures. It is therefore highly
If you look closely you can see CSF dripping
from the upper eyelid wound. This rare sign has
significant implications - it indicates a skull fracture.
This patient sustained a direct blow to his face
when the doors of a lorry swung round. He was
bleeding from the face and becoming increasingly
swollen. A good example where laying the patient
down would have put his airway at high risk.
Some initial considerations
Facial injuries form a large group of patients
and will commonly be seen, either in
isolation, or combined with other injuries.
In the UK it has been estimated they
comprise about 4% of all attendances to
the emergency department. However, there
are wide geographical variations in both
incidences and types of injuries. In the UK,
the incidence of gun-related facial injuries
is relatively low. However interpersonal
violence resulting in blunt trauma is
relatively high, particularly in large towns
and cities (approximately 25%). In the US
in 2007, 407,167 emergency department
attendances had sustained a facial fracture.
Not surprisingly the common groups are
young adult males and children. Frequently
Winter 2016 | Ambulancetoday
Widespread injuries to the face. If kept supine the
airway would be at risk and bleeding from the face
would not be recognised.
likely that ambulance crews / paramedics
and other first responders will encounter
these patients regularly and whilst most
patients will have relatively minor injuries,
there will be those with more significant and
potentially serious ones.
The patient with facial injuries poses three
important “Ds” in management - deception,
distraction and difficulty.
1 Deception - Even seemingly minor injuries
can progressively deteriorate, or remain
unrecognised unless they are specifically
considered. This is especially the case in the
supine and perhaps restrained patient.
i) Nasal bleeding and CSF leaks may not be
apparent if the patient can swallow.
ii) Just like facial burns, progressive swelling
of the face may quickly interfere with the
airway. Patients on anticoagulant medication
are at particular risk.
These have obvious implications when
transferring patients long distances. A clue
to an impending threat to the airway is
repeated requests or attempts by the
patient to sit up.
2 Distracting. Because of their obvious
nature one can often be drawn towards the
face when carrying out an initial assessment.
Nevertheless we must always be mindful of
the presence of occult and perhaps more
severe injuries to the brain, cervical spine
or below the collarbones. Life-threatening
facial haemorrhage is relatively uncommon
and in the shocked patient it is important
to consider the possibility of blood loss
elsewhere.
Biography:
Mike Perry
Mr Perry is medically and dentally
qualified in the UK. In 2011 he was
listed in The Times Magazine as one of
the country’s 50 top surgeons.
He completed surgical and dental
fellowship training (FRCS and FDS)
in the North East of England before
training in maxillofacial surgery in and around London.
Further experience was gained abroad at both a
leading trauma unit (Sunnybrook Hospital, Canada)
and leading craniofacial unit (Sahlgrenska University
Hospital, Sweden).
Mr Perry has over 15-years hands-on experience in the
management of facial injuries of all kinds (both facial
fractures and facial lacerations) and currently clinical
lead in facial trauma. He has over 45 peer-reviewed
publications, including several texts.
First appointed as a consultant to the University
Hospital of North Staffordshire in 2001, Mr Perry later
relocated to Belfast in September 2004, due to his
trauma interest, gaining over 10 years of experience
as clinical lead in craniofacial trauma for the entire
province. In 2014 he was recruited back to London to
develop the trauma / deformity / skin cancer service.
Mr Perry is actively involved in education, runs
several courses and has lectured both nationally and
internationally.
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