FACE, NECK, & EYE INJURY

WHY? Body armor works –9% mortality of injuries, compared to 24% in Vietnam or 30% in WWII Improved compliance with Kevlar wear Remaining exposed areas are face, neck, and extremities –22% of wounded with brain/head/neck injury, compared to 12% in Vietnam

ANATOMY Soft Tissues –Includes parotid glands Bones –Facial and cervical spine Neck blood vessels –Carotid and vertebral arteries –Jugular and other veins Trachea Esophagus Globes and surrounding ducts

ABC’s REMAIN BASIC! Soft tissue or bony injuries may immediately threaten the airway –Uncontrolled bleeding can change “stable” to “unstable” very quickly –Standard maneuvers may be less successful in setting of fractures, etc. Associated brain or spine injuries may cause airway loss as well –All blunt face/neck trauma must be considered at risk for C- spine injury –Neurologic injuries may worsen with time as well

TRACHEAL INJURIES Securing the airway remains critical Tracheal injuries may cause significant air leak –Pneumomediastinum –Pneumothorax, even tension pneumothorax Surgical repair is required –If unavailable, manage with secure airway and chest tubes if necessary –Minimize airway pressure on ventilator

BLUNT TRACHEAL INJURY Pneumothorax and Pneumomediastinum Tracheal Injury

EPISTAXIS May result in significant bleeding Separated into anterior and posterior sources Intubation for airway control prior to packing may be needed

EPISTAXIS Posterior Packing

EPISTAXIS Anterior Packing Epistat Balloon

ZONES OF THE NECK

ZONE 1 INJURY Difficult to access from neck incision, may need sternotomy/thoracotomy Initial management with angio/CT angio, bronchoscopy, esophagoscopy –Basically need to evaluate all vascular and aerodigestive structures potentially in harm’s way As with most trauma, “stable or unstable” guides the initial management –Active bleeding, expanding hematomas, or hemodynamic instability need to be addressed first in the OR and then with staged work up if indicated

ZONE 2 INJURY Only zone that is easily accessed from a neck incision Still requires investigation of vascular and aerodigestive structures In a STABLE patient, can be investigated with CT and endoscopy potentially Again, unstable patients or those with active bleeding issues need to be addressed in the operating room!

ZONE 3 INJURY Similar to Zone I, potentially difficult to access surgically and so angiography or CT needed, with possible endoscopy –These tend to be vascular injuries at the skull base that are very difficult to control surgically Again, instability should prompt rapid damage control in OR, followed by additional work up if needed

STAB WOUND - CCA

VASCULAR INJURY COMPLICATIONS Hemorrhage is the first concern Stroke is the second concern (up to 25% of ICA injuries) Revascularization may be required ICA/ECA Injury with Reconstruction

BLUNT CEREBROVASCULAR INJURY More frequent that was believed in the past –Roughly 1-1.5% of blunt admissions Workup with CT Angio or conventional angiography Treatment based on grade –Low grade lesions no intervention or ASA –Higher grade lesions need anticoagulation or possibly stenting, with recent interest in aggressive antiplatelet agents Complications related to increased stroke risk

BLUNT CEREBROVASCULAR GRADES

FACIAL FRACTURES Frequent injuries, but rarely have to be addressed immediately from a surgical standpoint The primary question should be one of airway protection –The anatomic disruption or bleeding may cause loss of airway –The situation may deteriorate as swelling progresses in the upper airway Remember that the globes may be injured by fractures and a good exam, including visual acuity, is mandatory

UPPER FACE FRACTURES Clinical exam is very useful – pain, bruising, crepitance, movement Malocclusion often occurs with mandible fractures Check a cranial nerve exam!

LE FORT FRACTURES

MANDIBLE FRACTURES Malocclusion a common hint on exam 50% will break multiple places Can be managed with soft diet/liquids and pain control in short term Operative repair ultimately required Panorex

FACIAL FRACTURES Open fractures may require broad spectrum antibiotic coverage –This isn’t agreed upon, but if a sinus is violated then initial coverage is reasonable Remember that if enough trauma occurred to fracture bones, the nearby structures are also at risk –At least 20% of facial fractures will have a TBI –About 2% will have a C-spine fracture

OCULAR INJURIES Evaluation requires a careful exam, including visual acuity Open globes are as emergent as threatened limbs, and need antibiotic coverage like open fractures Remember that open globes need an altitude restriction for MEDEVAC

OCULAR INJURIES Layering of blood in the inferior anterior chamber Usually managed with rest, elevation of HOB, and correction of clotting factors 5% will require surgical evacuation Hyphema

OCULAR INJURIES Minor injury Resolves spontaneously, though may take weeks Avoid anticoagulant or antiplatelet drugs Lubricant eye drops as needed Subconjunctival hemorrhage

SUMMARY Airway control remains the primary concern Control of hemorrhage may require packing, angiography, or operation Facial fracture repair may be delayed if necessary once wounds are closed Tracheal and esophageal injuries require more urgent repair Globe injuries should be considered with facial fractures, and known injuries treated with the same urgency as threatened limbs

QUESTIONS ?