Ambulance

Clinical Focus on Transferring Facial Injuries
This patient sustained an injury to his forehead
when he fell off a moped. You can see the right eye
is looking in a different direction to the left. The eye
didn’t move very much. This represents a significant
injury at the back of the eye socket.
v) Hyphaema (fresh blood in front of the
Iris)
vi) Irregular pupil
vii) Obvious eyelid wound
viii) Collapsed or severely distorted globe
A well-defined blackeye usually indicates a fracture
involving the eye socket.
Unfortunately, visual assessment in the
unconscious patient is extremely difficult.
Assessment can only rely on pupillary size
and reaction to light and careful assessment
of globe pressure by palpation, if there is
proptosis. Because of the close proximity
to the brain, penetrating intracranial
injury should always be considered in all
penetrating orbital injuries, even if not
immediately apparent.
Loss of the eyelids. This, or the inability
to effectively close the eyelids, quickly
results in drying of the cornea, ulceration,
and potentially loss of sight. Appropriate
protection during transfer is therefore very
important as failure to do so could result
in litigation. This is especially important in
the unconscious patient. Eyelid lacerations
may also indicate the presence of a serious
underlying ocular injury. If possible, eyelid
remnants should be pulled together to
provide corneal cover. Liberal application
of chloramphenicol ointment or should be
administered and the whole area covered
with a protective, non-adherent cover,
such as an eye shield of plastic galipot. The
tetanus status should also be checked.
Proptosis of the eye requires prompt
treatment. Like any compartment syndrome,
the longer the raised pressure remains,
the worse the outcome. Ideally lateral
canthotomy and cantholysis should be
undertaken. This effectively detaches the
supporting, suspensory ligament of the eye
Winter 2016 | Ambulancetoday
from the eyesocket, thereby allowing the
eye to move forwards, reducing the pressure
behind it.
Finally, as elsewhere, mobile facial fractures
should be temporarily stabilised whenever
possible. Separation of fractures and
movement between them is not only painful,
but can result in continued bleeding and
swelling. Often a well fitting collar will do
much to support the facial skeleton during
the transfer process, but this does come at
the price of restricting mouth opening and
airway protection.
Some useful mechanisms of injury
Understanding mechanisms of injury is an
important part of the assessment of any
injured patient, especially when considering
the possibility of occult (hidden) injuries.
This is equally so in maxillofacial trauma. It
is perhaps useful therefore to think of the
head and neck region as four separate, but
interconnected anatomical sites. A useful
mindset of ‘think brain, neck, eyes and face’
will serve us well – when we see an injury
in one, think of the possibility of injuries in
the others – they do often co-exist. Of all
these sites, the face is the lowest priority, so
long as the airway is secure and there is no
ongoing haemorrhage.
Although this patient has sustained obvious facial
injuries, it is important to remember injuries to the
brain, eyes and neck are also likely to be present.
Specific injury patterns reported to be
associated with certain mechanisms of injury
include:
i) Hyperextension injuries to the neck in
the elderly, following a fall onto the face.
ii) Blindness has been reported following
blunt trauma to the forehead in the absence
of fractures. Interestingly, this was first
noticed by Hippocrates.
iii) Successful airbag deployment has been
reported to result in severe ocular injuries.
iv) High energy projectiles can penetrate
both the eye and the brain as the
intervening bone is very thin.
v) Compressed air / blast injuries can result
in extensive facial emphysema.
vi) Blows to the chin can result in remote
fractures in the mandibular hinge joint
and tears of the external auditory meatus.
Bleeding from the ear may result in
diagnostic confusion.
vii) Fractures following an impact to the
bridge of nose can extend deeply to involve
the skull base and orbit, with risks of CSF
leaks and blindness.
viii) Rapid deceleration as seen in bungee
jumping has been associated with retinal
haemorrhage.
ix) Prolonged hypotension (from any cause)
has been reported to result in blindness.
x) Penetrating injuries to the palate,
typically seen following a fall with a pen /
pencil in the mouth, have been reported to
result in carotid injury and stroke.
xi) Widespread (‘’Panfacial’’) fractures are
associated with bleeding, swelling and airway
compromise. However these complications
can also occur in the absence of any
fractures, in patients taking anticoagulants
or with clotting abnormalities. Swelling
worsens when supine, from elevated venous
pressures and reduced lymphatic drainage.
xii) Hypertension during resuscitation
may precipitate intraocular bleeding. In
the elderly patient a dilated pupil may
precipitate ocular problems. Acute angle
closure glaucoma can be precipitated by
drugs and general anaesthesia—this should
be considered in any tense, painful, red eye.
Conclusions
Facial injuries are common and it is
likely ambulance crews / paramedics will
encounter them - probably frequently. Whilst
most injuries are minor, initial appearances
can be deceptive and they require careful
assessment, especially if the patient needs to
be transferred supine on a spine board. The
emphasis of assessment is on the patency
of the airway and the likelihood this may
be lost as swelling develops, and on the
presence of ongoing haemorrhage which
in alert supine patients will be swallowed.
The mechanism of injury is a useful guide to
predicting some injuries, particularly in the
unconscious or confused patient. Because
of its anatomical location it is prudent to
actively consider the possible association
of cervical spine, brain and ocular injuries.
Whilst there is not much that can be done
for the latter, failure to carry out simple
measures can result in significant visual
problems and possible litigation.
To find out more about Mike’s work
and to access great resources for
trauma enthusiasts everywhere, please
visit the website of the International
Society of Head and Neck Trauma:
www.headandnecktrauma.org
and youtube channel
(headandnecktrauma org)/
www.youtube.com/channel/UC_
kh2MVLAOwyXkiW2dDq4qw?view_
as=subscriber
To contact Mike Perry go to:
www.facialsurgery.center
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