Pediatric emergency medicine trisk 822

CHAPTER 107 ■ FACIAL TRAUMA PAUL L ARONSON, MARK I NEUMAN RELATED CHAPTERS Resuscitation and Stabilization Airway: Chapter Signs and Symptoms Epistaxis: Chapter 26 Injury: Head: Chapter 41 Trauma ENT Trauma: Chapter 106 Ocular Trauma: Chapter 114 Surgical Emergencies Ophthalmic Emergencies: Chapter 123 Procedure Procedures: Chapter 130 The Children’s Hospital of Philadelphia Clinical Pathway Clinical Pathway for Evaluation/Treatment of Child With a Laceration URL: https://www.chop.edu/clinical-pathway/laceration-clinical-pathway Authors: S Fesnak, MD; E Friedlander, MD; E Lichtman, RN Posted: February 2019 KEY POINTS Stabilization of the airway is the primary concern for children with facial trauma Computerized tomography is the optimal imaging study for suspected facial fractures Prompt recognition of extraocular muscle entrapment associated with orbital floor fractures is critical to prevent muscle ischemia and fibrosis Displaced nasal bone fractures should be repaired within days of injury Fast-absorbing plain gut sutures have demonstrated similar cosmetic performance to nonabsorbable sutures for the repair of facial lacerations GOALS OF EMERGENCY THERAPY Stabilization of the Airway While injuries sustained as a result of facial trauma are rarely life threatening, patients who have sustained enough force to cause significant facial injury may have other associated serious injuries Stabilization of the airway is therefore the primary concern in the management of facial injuries in children Airway obstruction may result from blood in the mouth, loose teeth, and pharyngeal edema Thus, the airway should be cleared and examined for patency Loss of support of subglottic musculature can result from severe mandibular fractures, and the tongue can fall posteriorly and occlude the airway in a patient with a depressed mental status An oral or nasal airway may serve as an adjuvant to positioning in order to achieve airway patency Tracheal intubation may be required if the airway remains unstable Cricothyrotomy or tracheostomy may be necessary if these measures fail to secure the airway but should be attempted only as a last resort because of the technical difficulty and complications associated with such procedures, particularly in young children Cervical Spine Protection Up to 10% of patients with maxillofacial trauma have an associated cervical spine injury Patients with tenderness of the cervical spine, impaired sensorium, focal neurologic deficits, or major distracting injury should be placed in a hard cervical collar until an injury to the cervical spine can be excluded Identification of Specific Bony Injuries and Facial Neurologic Deficits Following airway stabilization and cervical spine protection, examination for specific bony injuries should be performed After careful observation for deformity and asymmetry, the clinician should palpate the facial bones in a systematic fashion ( Fig 107.1 ) Tenderness, crepitus, and “step off” are signs of underlying fracture Particular attention should be paid to the malar eminences, zygomatic arches, and superior and inferior orbital rims Assessment for a fracture of the maxilla can be performed by grasping and attempting to move the upper central teeth Any laxity of the maxilla or crepitus is suggestive of fracture External and intraoral palpation of the mandibular symphysis, body, angle, and ramus can help diagnose fractures in these areas Inspection of the mouth and oral cavity should also be performed to assess for injury to the maxilla and mandible Occlusal disharmony is an indication of mandibular and/or maxillary displacement Older children will be able to report if their bite “feels normal.” Opposing teeth that not come together, but that exhibit wear facets (smoothing of mammillations along the incisal surfaces of the teeth) suggest a traumatic malocclusion An inability to hold a tongue blade between occluded teeth on each side of the mouth is suggestive of a mandibular fracture Examination of the eyes should include the assessment of pupillary reactivity and size, examination of extraocular movements, visual acuity, and a thorough inspection for surrounding orbital injuries Orbital dystopia and/or enophthalmos are suggestive of a fracture of the orbit Examination of the nose should include documentation of focal tenderness, swelling and asymmetry, bleeding, or other nasal discharge, as well as the presence or absence of a septal hematoma FIGURE 107.1 Sequential steps in examination for facial fractures A: The supraorbital ridges are palpated while keeping the patient’s head steady B: The infraorbital ridges are palpated using the index, middle, and ring fingers to assess for areas of point tenderness C: The zygomatic arch is palpated on each side to determine continuity and the possible presence of ... similar cosmetic performance to nonabsorbable sutures for the repair of facial lacerations GOALS OF EMERGENCY THERAPY Stabilization of the Airway While injuries sustained as a result of facial trauma