Chapter 24. Facial injuries
Most facial injuries will be managed as part of the secondary survey. Severe facial injuries may however compromise the airway through anatomical disruption or by bleeding.
Airway problems
Airway problems arise from:
• Inhalation of foreign bodies
• Posterior impaction of the fractured maxilla
• Loss of tongue control in a fractured mandible
• Intraoral tissue swelling
• Direct trauma to the larynx
• Haemorrhage.
Severe facial injury may necessitate advanced airway procedures such as cricothyroidotomy.
Circulatory problems
Haemorrhage from facial fractures may produce:
• airway obstruction
• hypovolaemic shock.
Two percent of facial injuries have associated cervical injuries and the patient’s cervical spine should be protected using a semi-rigid collar, spine board and head blocks until injury can be excluded.
Soft tissue injuries
Soft tissue injuries may be divided into superficial cuts and grazes, lacerations and penetrating wounds. There may be loss of tissue or degloving injuries, as seen for example in the lower labial sulcus (groove behind the lower lip) when the skin over the chin is forcibly pushed downwards and backwards.
Treatment
• Profuse haemorrhage from cuts and lacerations should be stopped during the primary survey. Pressure applied over the wound with a gauze swab held firmly in place may be all that is required
• Penetrating injuries should not be explored. It is dangerous to explore neck wounds, which should be covered and managed in hospital
• Foreign bodies should be left in place, including those piercing the cheek or penetrating the other intraoral tissues, unless they are causing airway obstruction
• A cheek wound may sever the parotid duct, resulting in an escape of saliva onto the cheek
• During the secondary survey a thorough examination of the scalp and face will be carried out in order to identify all the soft tissue injuries.
Eye injuries
The most common superficial injury is a corneal abrasion in which the superficial layers of the cornea are removed. The resulting injury is exactly analogous to an abrasion of the skin and is very painful.
Blunt injury to the globe of the eye can produce a variety of injuries including haemorrhage into the anterior or posterior chambers and injury to the individual structures of the eye.
As well as a late sign of intracranial haemorrhage a unilateral dilated pupil may be caused by severe concussion to the globe (traumatic mydriasis). Similarly a unilateral constricted pupil may result from blunt trauma to the eyeball (traumatic miosis).
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