← Emergency Medicine Cases
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Emergency medicine is more than just ordered chaos.
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From the recess room to the bedside, we are witness to it all and
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we're here to help you prepare for it.
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Bringing you the brightest minds in emergency medicine from around the world for trusted, tried and true free open access medical education.
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I'm Dr. Anton Hellman.
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And I'm Dr. Katie Lynn.
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Katie, let's welcome the listeners from our amazing EM community to the Emergency Medicine Cases Podcast, shall we?
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C
Yeah.
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Or let's simply call it EM Cases.
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Okay EM Cases. EM Cases is brought to you by shremi, the Schwartz Reisman Emergency Medicine Institute that's a non profit organization dedicated to improving EM care through high quality research and education. The opinions expressed on this podcast are intended for information and education purposes only and should not be used to diagnose, treat or prevent any medical condition. Nor should they be used as a substitute for medical advice and followed by practice physicians.
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First, just a quick word from our sponsor Metricade, the experts in complex physician scheduling since 2012 I've been using Metricade's incredible scheduling system for more than a decade and it's been a game changer for me and my colleagues. Shift work comes with its challenges, but Metricade helps minimize the drawbacks by ensuring fair distribution of shifts while integrating circadian rhythm friendly recovery time into its methodology. Preserving your precious sleep so that you can perform at your best. Go to metricade.com emcases to see how Metricade can make your scheduling fair and improve your sleep and your performance. That's metrocade.com emcase facial trauma is everywhere in emergency medicine.
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We see it after assaults, NBC's falls, sports injuries, sometimes isolated, sometimes as part of devastating polytrauma. And while many facial injuries are not immediately life threatening, the misses can be catastrophic. A threatened airway you didn't anticipate a retrobulbar hematoma you didn't catch a septal hematoma that necroses or perhaps not catastrophic, but a patient who gets transferred or not transferred unnecessarily. And when it comes to facial fractures, the challenge isn't identifying any fracture, Connecticut will do that. The challenge is knowing which facial injuries actually matter in the ed, which ones need urgent action and which ones can safely go home with good instructions and follow up. In this episode, we're going to give you a top down practical approach to facial injuries, starting with airway and bleeding, moving through wrist stratification exam pearls that actually change management pitfalls and soft tissue injury management. Key CT findings you need to know and finally, disposition. Who needs plastics now who needs transfer and who definitely does not. I'm super excited to welcome our guest experts, one of whom is new to EM Cases and the other I suspect you all know very well by now. Dr. Jeff Fialkov is a Toronto based plastic surgeon, the head of the division of Plastic Surgery at Sunnybrook Health Sciences center and associate professor at the University of Toronto. He specializes in complex cranio, maxillofacial trauma, reconstruction and cosmetic facial surgery. With an international reputation for training surgeons in advanced techniques. Welcome TM Cases, Jeff.
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Thank you Anton. Very happy to be here.
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And back by very popular demand as always, Dr. Andrew Petchisoniak, otherwise known as Petro, Trauma team leader, emergency physician at St. Michael's Hospital, master educator, someone EM cases listeners know well from his incredible contributions to the main podcast, the EM Quick Hits and the EM Cases Summit. Andrew, it's great to have you back, man.
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B
Yeah, thanks for having me. Kind words, I appreciate that.
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A
Let's dive in and start with a case. A 34 year old man presents after being punched repeatedly in the face during an assault outside a bar. He's alert with stable vitals. He's speaking in full sentences but has significant mid face swelling. He's got epistaxis that requires pressure to control and he's got periorbital ecchymosis bilaterally. He also tells you that his bite feels off and he complains of double vision on exam. He's got marked facial swelling, he's got tenderness over the nasal bridge and the infraorbital rims. There's obvious malocclusion, he's got limited upward gaze on the right, he's got mild trismus, no obvious septal hematoma and his GCS is 15. There's no other obvious injuries. His C spine's not yet cleared. So let's start with kind of just the first few minutes at the bedside. Andrew, in a patient like this, facial swelling, bleeding, malocclusion, diplopia, but stable vitals, what's your just sort of immediate impression? What are you most worried about right now? What do you want to know before you get a ct? What management decisions are you already making before imaging even comes back?
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B
This is fairly common. I think we see this across emergency medicine across the country on a regular basis. These patients key is obviously like most of us are well aware is just do a good airway assessment. They may come in with a patent airway, but you know, swelling will progress over time. Sometimes there's injuries hidden behind the C collar, so I will take the C Collar off. Just have a look and see what I'm dealing with in terms of the neck. But most of these patients, it's clear that this patient has injuries that likely are going to require him to get a CT scan. He's got trismus, he's got malocclusion, and he's got limited upward gaze. And so all of these put together are, you know, increasing my suspicion that he's going to have something structurally abnormal on ct. But we're also seeing sort of good hemodynamics. So the rush to do anything is really just make sure that we don't have other signs of injury that are going to require me to do other interventions, CT scans that you're going to need to do, and which we'll probably get into shortly.
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A
Yeah, absolutely. We'll get into all the details of resuscitation and the immediate things you worry about and all the different diagnoses we're talking about, which we've already hinted at. Jeff, sort of your immediate general impressions?
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C
Yeah, I mean, I come at it from a bit of a different perspective. By the time we see these patients, people like Andrew have already stabilized them and ABCs have been taken care of. But that's always paramount. And part of our role in the ABCs is to look for things that may not necessarily come to mind immediately. Things like loose teeth that could actually lodge in the airway and cause a problem. So sticking a finger into the mouth to make sure there are no loose teeth debris, loose pieces of bone, all of those things actually could obstruct breathing, generally speaking, facial fracture collapse or instability, which clearly this. This patient has multiple facial fractures. It's very obvious from the initial description. It's rare that those in themselves cause airway obstruction. It's primarily foreign objects, foreign material, teeth, pieces of bone, or bleeding. So those are the two things that immediately I would want to ensure were addressed prior to proceeding with ct. That
- [07:22]
A
segues very nicely into what our priorities are going to be with this patient. Right now, he's stable, but, Andrew, from your perspective, you know, as a trauma team leader, let's just assume for now that there's no chest or abdo or back or extremity injuries. So you're just really concentrated on the head and neck. What are the airway bleeding and associated injuries you're thinking about immediately? Besides what Jeff just mentioned in terms of foreign bodies and such?
- [07:50]
B
I think I. I sort of divide it between. Is it, you know, my first kind of decision point or bifurcation for these patients is do they have airway or hemodynamic compromise now or am I anticipating that in kind of the near future, am I able to oxygenate them? Is there a probability that there's also a neck injury or a, you know, soft tissue injury, disruption of the larynx? And so this is all going to kind of complicate the process if we have to manage the patient's airway. And so those are the kind of, the first, that's the first level of bifurcation. Otherwise I'm looking at, okay, is there structural injury like Jeff mentioned? This patient clearly has facial bone fractures, but they're stable. And so in that case, then I can kind of pause and do a little bit more of a detailed neurologic exam, ophtho exam. But in the first situation where I'm worried that they are going to deteriorate or they have already deteriorated, going ahead and preparing for, you know, definitive airway management really is something I'm going to try and get ahead of in these patients. In addition, the hemodynamics, you know, not always is it bleeding that's causing the hemodynamics. Just recently we had a patient who had a massive facial injury and their hemodynamic compromise was actually because of the brain injury that they had suffered. And so keeping that in mind that it of course we're going to treat these patients like bleeding or that they, we assume they're bleeding, they're a trauma patient and we will give some blood. But ultimately, many times they've actually sustained such catastrophic brain injuries that they are now hemodynamically compromised. And so keeping that in mind, and that the reason that matters is because you might adjust your plan, neurosurgery might be involved earlier, you may adjust your plan with respect to hemodynamic targets, a more neuro focused resuscitation. And so I think, you know, we have to realize the face is not very far from the brain. So these patients can have substantial brain injury. And it's often quite obvious that these aren't. The patient you just described is not that patient. But it is one that I am kind of keeping in the back of my mind.
- [09:51]
A
Yeah, thinking outside of the face, brain, neck. We'll talk about vascular injury a little bit later, but there's all kinds of other things we need to think about. I want to zero in a little bit more on the airway. And in this case the patient's airway seems obviously fine. But again, like you said, we need to anticipate that the airway might go south, we did talk in depth about airway in trauma. Trauma to the airway and airway and trauma in general in our big episode we did with George Kovacs a little while back. But just in this context, if you could just highlight for us some of the airway considerations when it's specifically a facial smash.
- [10:32]
B
Yeah, I think, you know, the, the need to characterize the facial bone fractures is a Psilophore 2 or 3 or, you know, isn't an immediate priority that'll be, you know, characterized on CT scan. And you can't do that really clinically very well, at least in, you know, catastrophic facial injury. Jeff already made the point and I think it's true. Like the probability that the whole face just collapses due to structure isn't that high. You know, it's not that common where that happens. But in the textbooks, you'll, you know, they'll, that will be outlined, you know, when you do the RSI or if you decide that you, you're going to paralyze these patients, you can lose the, the structural integrity of the. Because it just fully collapses. So I think you have to be prepared for that. I think the bigger challenge is, is just applying a BVM to these, A face like this where it's just moving around on you, that's probably more difficult. So I think being set up with, you know, a suite of options for the intubation is, is probably key. I think the point of this, you know, this session isn't to kind of go through all of that, but being quite adept at, you know, understanding that there's a chance that you might need to crank the patient, that you need to get, you know, front of neck access. But also having, you know, you may want to be cautious with, with paralytics until you have an understanding of exactly what you're going to get into. You know, being able to have a fiber optic at the bedside and, and, or your best intubator, you know, and this may involve including anesthesia in the management of these patients because you can get in there and you have, you know, virtually no access into the, the larynx. And so I think it's important to, to be humble for these patients.
- [12:10]
C
Just to interject on that note, Andrew's absolutely right. You sort of have to be prepared for anything. And there is one facial fracture pattern, as you probably know, that is kind of classically associated with blocking the airway, obstructing the airway when the paralytics take hold, and that's the bilateral parasymphyseal. Fracture. So both sides of the mandible are fractured and all of a sudden the tongue has no anterior support. And as soon as you paralyze the patient, the tongue falls back. Sometimes you don't even have to paralyze the patient. That can happen. That's probably the one facial fracture where you may more commonly see a problem with obstruction than any other. So if there's a mandible fracture and you notice that, you know, the tongue seems to be lax, there's a bit of obstruction higher up. One thing you can do, which is very simple thing to do, is to grab anything, a towel clip, a suture, stick it in the tongue and just pull the tongue out and hang it off the side of the chin or with something heavy, a heavy clamp, or suture it to the chin. If you're worried about the obstruction, you're worried about the tongue actually falling back. It's a very simple thing to do. Usually we just use a towel clip to do that. If there's any question.
- [13:19]
A
What an amazing pearl. That's incredible. I'd never heard of that. Even so, bilateral mandible fracture, particularly the parasymphesis.
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C
So on either side, the fractures usually occur in stress risers. So one of the stress risers is the mental foramen. So you've got one on each side. If there's an impact, usually directly, say on the mentone, right on the chin, you may have a fracture bilaterally there. And then all of a sudden the floor of mouth has lost its anterior structural support and you could potentially. That's sort of, you know, the classic textbook facial fracture associated with airway obstruction. So if that's the case, if there's any question, and it's a very innocuous thing to do, believe it or not, sounds absolutely horror film, but it's not. You just stick something in the tongue and just pull it forward and you can always clamp it into position. If you have any question as to whether that's the obstructing body, that's a good pearl.
- [14:14]
A
Amazing. Like life saving and simple, easy. But you gotta know to anticipate that. Fantastic. So if you are confronted with a patient who's had a facial smash and you can see that there's torrential bleeding, how do you handle that situation?
- [14:31]
B
Yeah, I think, I mean, most of us are accustomed or at least familiar with an approach, you know, your hemodynamic approach, you're getting blood in, you're giving txa, all of that type of stuff. And then now the more tailored or focused approach on the management of bleeding within the airway. So suction catheters, you're trying to obviously go ahead and secure the airway and you know, we won't get into the details of exactly what. We've talked about that with George before on the podcast, but understanding that the need for securing the airway is paramount in those instances once secure and, and Jeff probably has some insights on this as well because that's when, you know, we often involve the plastic surgery team. You're just trying to pack with whatever you can from the inside out, assuming that there is still structural integrity, like on the skin, on the outside, so that you can kind of tamponade outwards. You can also repair, even temporarily. The goal is not cosmesis at this moment, it's just put some sutures in on the, you know, on the surface of the, on the face, on the skin to clamp downwards. And then I'll pack the mouth with bilateral Foleys into the, into the nose or some type of tamponade within the nose. And you know, if it's, if I think it's more posterior, I'll go right back with the Foley all the way, all the way back past the nasopharynx. If there's other skin openings where I think there's bleeding, I will try, you know, just like we do in the neck. I'll put a catheter and try and blow it up with a, pull a Foley catheter into, into one of the openings to see if I can get some tamponade there. And then I think you have to realize that these, some of these patients, and obviously it's a challenge when you're in a rural environment. Some need neuro, interventional. I mean, these aren't amenable to neurosurgery, Some might be amenable to plastics. And Jeff could talk about which ones those are, but some are deep and you just can't access. It doesn't matter who you are. The only way is a catheter directed approach. And so I think we have to understand that there is a subset of patients where that is really the only option to stop the bleeding. So your best bet is pack the mouth with gauze. You know, that you can, you know, you're tamponading as much as you can around the endotracheal tube and then really just any option to put in balloon catheters to sort of fill space is going to be paramount. And then, yes, if at some point you're going to try and get to Imaging to understand if there's hemorrhage and anything amenable to neuro interventional, which is a big challenge when you're, you know, three hours away from neuro interventional.
- [17:04]
A
So great. Jeff, any tips on packing the face when there's torrential bleeding?
- [17:09]
C
It's funny, the first thing I thought of when Andrew, when you asked Andrew that question was call interventional radiology. Tells you where I work, right? Yeah, I mean, you're absolutely right. There are just some instances. The worst bleeding probably comes from branches of the internal maxillary and they're probably associated most with mid facial fractures and probably mostly with penetrating trauma as opposed to blunt trauma. And in those instances, it's very hard to get any definitive control over bleeding. And I agree 100% with Andrew, you, you've just gotta temporize and if you can get them to a trauma center or you're lucky enough to work in a trauma center, get them to interventional radiology because that's something that you're only going to be able to stop either with IR or by taking them to the operating room and tying off a branch of the external carotid or gaining control over the external carotid itself, which I've had to do in the past, actually. So the key is temporization. Now one of the tricks to, to temporizing your tamponade is actually to reduce the fracture. And this is particularly true in midphases. So once you've secured the airway, you don't really care what's happening in their mouth so much anymore. You can actually just bring them into as best an occlusion as you can. Probably not true occlusion because the tube, the ETU tube is in the way. But as long as you're reducing their maxillary fracture by pressing upwards, sort of cephalide pressure, you, you may actually tamponade the bleeding better than anything else. So if you find, I think packing initially is a great idea, sometimes you can't access those posterior branches of the internal maxillary with your packing and it just kind of bleeds around the packing. If you're finding that's the case and you're just not gaining control. Once you've secured the airway, just shut the patient's mouth, get that maxilla, or even just grab the maxilla and use your fingers on the teeth and tamponate it upward. Just try to reduce that fracture. Just like in good old orthopedics, you know, the reduction of the fracture is what usually facilitates the hemostasis.
- [19:11]
A
So another great pearl so packing with gauze, Foleys, whatever you got, and then seeing if you can reduce either the mandible just by pushing cephalad.
- [19:24]
C
Yeah, you're basically trying to just push the maxilla up into compression where it's fractured at whatever. You know, usually LeFort one fracture line is where the bleeding is happening from.
- [19:34]
A
Great. We had hinted that we need to be thinking about the brain and the C spine and other things. I want to dig into that a little bit further. So, you know, one of the biggest pitfalls is having sort of tunnel vision on the face, because it's usually pretty dramatic when someone gets a really bad facial smash is you're just concentrating on the face, and you can forget that there's other injuries that are very important as well. Which are the other injuries outside of the face that are most commonly missed, that we really need to kind of tick off our checklist of other injuries.
- [20:09]
B
So I think in terms of catastrophic injuries or potentially significant injuries, cerebral vascular injuries are, I think, the ones that we would worry about due to the potential sequelae. I think that in severe trauma, the probability those are missed now because that patient ends up at a trauma center, they're going to get Connecticut carotid, a CT angio, and our awareness around that is much lower because you don't need to diagnose that within the first even 12 hours, arguably, because the treatment is antiplatelets. And if there is an injury, typically, and what you're trying to do is prevent sequelae of stroke over the next seven days or several weeks. So that's probably what's most important. I think where we might miss a BCVI or a cerebral vascular injury is in the patient you described at the beginning, where we didn't realize that they could have an injury. They're not the intubated trauma patient that's gonna get pan scanned five times. It's the patient that we're gonna send home and follow up with Jeff in clinic that we forget or don't appreciate that if you go through the modified Denver criteria, which are a set of criteria that can help support when you should worry about these patients for bcvi, those are the patients, perhaps, that we would miss. And that. And I think it's worth knowing those criteria. I think going through them right now, probably on the podcast, I think it's probably best to just put them in the show notes. But it's basically a set of criteria that look at injury pattern, signs of immediate vascular injury, and then subsequent injuries identified on. On ct. And. And some, you know, it's a bit. You sometimes have to get the imaging to know that, oh, the patient has a mandible fracture or Lefort ii and as a result they're at risk for BCVI in terms of things that, you know, C spine injuries. I think most of us are imaging C spine during these instances, so I think that's not so much of an issue. I'd say the two misses are ocular injuries and hearing injuries because I think we often don't necessarily screen particularly hearing. I don't think we do a great job of screening them in the ed. Did somebody examine in the ear to see if they have hemotympanum or anything like that? Is there some canal injury and ensuring that they have subsequent appropriate follow up and then ultimately ophtho injuries? I think both of those can sometimes be pushed aside because people are so focused on what's obvious, which is the facial disruption.
- [22:43]
A
So that's a great pearl. Just to make sure you take that off your list to at least test their gross hearing and take a good look to see if there's any canal damage. Hemotympanum, usually we're pretty good at checking with any head injury, but I think
- [22:57]
B
we've moved more towards CT as our exam. And so I think that we, you know, and we rely on the radiologist to comment are there, is there disruption in the canal or you know, for hearing. And so that's what we rely on. But ultimately there's a functional element to hearing, which is important, that needs to be documented. The same with vision. You can have no findings on CT and yet the patient can have visual disruption.
- [23:21]
A
So yeah, absolutely. I think a theme running through this podcast is going to be that CT doesn't give us everything. And actually it's going to be the physical exam that really is extremely important. And we're going to go through all the pearls and pitfalls with the physical examination a bit later on. I want to talk about the indications for imaging in facial injuries. And this is going to depend somewhat on the mechanism, but heavily on the physical exam. Andrew, what are some of the key physical exam findings that trigger you to go ahead and order imaging? I mean, obviously in the case that I, that I presented at top, they're going to get imaging for sure. You know, there's some findings that are like almost pathognomonic and some findings that are really subtle. What are some of the things that you look for in a patient who presents, say with a punch in the face or a baseball to the face or we'll Talk blunt trauma first.
- [24:14]
B
Yeah, I mean first of all, my threshold now I think is really diminished in terms of the need for facial imaging. So I'm pretty liberal with it broadly. I mean many of these patients are getting a CT head, the subsequent radiation add on from doing the face, you're just doing some finer cuts. And so if I'm seeing any really significant disruption, swelling, I'm often order adding on a facial bone, getting facial bone cuts. I'll palpate along the face. These are for maybe the minor trauma patients, the ones that are not coming in to see me when I'm on trauma as ttl, but patients that come in like you described, but if they have significant tenderness over the face on any of the bony prominences, I'm pretty liberal with, with imaging especially when the, the mechanism fits with, you know, you punched in the face and now you have significant tenderness over the maxilla if there's malocclusion, some trismus and, or any disruption of the globe position. So my, my threshold's pretty low. I guess as a caveat, you know, if you don't do facial bone imaging, there's a good chance the CT head will pick up the facial fracture. It's just a matter of, you know, Jeff then will want finer cuts to make, subsequent decision making. So if you miss it on the first pass because you're imaging the head, then there's a good chance that you'll see fluid in the sinus on the CT head, that then you can just go back and you know, maybe, maybe you don't see the fracture because it's subtle. I think the bigger issue would be, is if you omit imaging altogether and you're trying to make a decision, oh, I think this patient's fine. I don't think they have any problems. Perhaps the importance of the physical exam goes up. But I think if I have anything greater than, I think like a 10 or a 20% chance of a facial bone fracture, like I'm going to probably image 1 or 2% if I think it's all, it's probably not likely I won't image.
- [26:10]
A
Fair enough. There's a few questions I have. One is many emergency departments like my own, in the middle of the night, you can't get a dedicated facial. All you can get is a plain CT head. In rural places you have to transfer the patient for CT anyways. All they have is X ray. Can you just give us a few tips Jeff, on how to make these decisions on when do they absolutely need to be transferred for a ct. When do they absolutely need a CT of the face, not just the head? And then I understand there's also like temporal bone cuts that you can ask for. When should we be ordering each of those? So again, there's X ray, plain CT head, plain CT head with facial bones, and then there's also temporal cuts.
- [26:55]
C
The quick answer is it depends what you have. Right. So I do a clinic in Rankin Inlet in Nunavut where we only have plain films, we don't have ct. The standard of care at this point is really to if you suspect a facial fracture, it's to do a CT scan. That's what we do at Sunnybrook. But when I'm not at Sunnybrook and when I'm at Rankin Inlet, a plain film will give you information that will at least allow you to make the diagnosis so you know to refer the patient. The problem is. So for instance, Townes Waters View, Basilar View, at the very least you'll be able to see a fluid level in the sinus, you'll see opacity in the sinus. That basically is almost certainly a fracture of some sort. What it's not good at is picking up things that may be surgical emergencies, like a radiographic sign of entrapment. But that's a clinical diagnosis anyway. So my suggestion for somebody who is limited to just plain facial films is rely on your clinical signs, use your plain X rays to confirm that there's something going on, just to give yourself a little confidence that when you refer, you're not doing it for no reason, and then send the patient down for CT and definitive management. And that's happened to us in Rankin Inlet, where I know the patient doesn't necessarily have any surgical fracture. In other words, they may not need surgery, but they need to have a CT scan to properly diagnose all of the fractures and to ensure that there's nothing worrisome in terms of long term sequelae, which we can talk about. So that would be my recommendation for a rural setting in an urban setting. I think, again, it depends what you have. A head CT certainly will give you a basic idea of whether there are upper and mid face fractures. They often will not go low enough to see the mandible, in which case plain films are perfectly fine for a mandible. You can make diagnosis of mandibular fractures on plain films, I'm sure, though I
- [29:01]
B
think it's actually harder. Like we. I don't even know if we can get a Panorex anymore. Like it's become increasingly difficult. So you do to get plain films.
- [29:08]
C
Yeah.
- [29:09]
B
It's actually easier to just get the ct.
- [29:10]
C
Right, right.
- [29:11]
B
Even at kind of urban center, obviously, if I think of in a rural spot, you know, you probably get the Panorex up in Rankin Inlet, but.
- [29:17]
C
Right, right.
- [29:18]
A
Yeah. That is an odd thing. Where I work as well, we can do X ray mandible, but they won't do Panorax.
- [29:24]
C
Right, right. Or they won't take your CT at night down to the mandible. They'll just give you a head ct. Right, yeah. So in that case, I think again, it's what you have. CT should be the standard of care if you suspect facial fractures. In my opinion, you should get a CT scan. If your clinical suspicion is high enough that you are worried about a facial fracture and you have a CT scanner, that's what it's for. And certainly if you have access to facial bone CTs, that is the standard of care. In fact, intraoperative CT is now the standard of care. So I think that, you know, we have the tool, it's accurate. Why not make the accurate diagnosis? It certainly makes the consultant's life easier. Because I don't, as Andrew pointed out, then I don't have to send the patient back to make that definitive diagnosis. So whatever you have, I would suggest if your clinical suspicion is high enough that you think the patient has facial fractures, just image it with whatever the most advanced imaging you have is.
- [30:22]
A
Let's say you get a plain CT head and you see a fracture there, what added value does the facial CT bring?
- [30:29]
C
Yeah, it's an excellent question and it may not give any added value. So I think if you have a simple CT head, no facial cuts, and you see that the fractured complex, let's say it's a zygoma fracture or even a nasorbal ethmoid fracture, you can tell from the CT that it's minimally displaced. There's no clinical indication that there's any significant displacement. The patient's not having any ocular or ophthalmic issues, then it doesn't add anything. And that might be sufficient for me when I see the patient in follow up. Absolutely. The biggest added value is when it comes to orbits. And the reason for that is because there are some surgeons. This is still. We can talk about this in terms of indications for orbital surgery, which we may have time for. There are some surgeons that will still use radiologic criteria to determine whether a patient needs prophylactic orbital floor or medial wall repair. Now, I am not a big believer in that, but that is a controversial point. However, if I want to really see what's going on in the orbits and particularly the orbital floor or medial wall, head CTs generally don't give me enough detail for that. But to see a simple zygoma fracture, and I'm sure clinically that there's no issue with the orbit and I can see from the head CT that it's not even displaced very much anyway, so I know the orbit is likely to not be an issue. Perfectly adequate, there's no value added to that. In summary, if you have the ability to get facial CT and you suspect a facial fracture, why not get a facial ct? I would say that's the thing to do. If you only have head ct, get a head ct, it may be adequate. Once the specialist has a chance to review it, it may give you everything you need to know. And much to your point, if you see on the head CT that there's minimal displacement, you know, follow up, you don't have to worry about urgent follow up. Follow up can be, you know, within a week or two weeks, let's say. So it does give you it, it potentially gives you a lot of information. And if you have nothing else, you can at least use plain films. If you're in a rural area, you can use plain films to confirm your diagnosis with fluid levels in the sinuses or a disruption on the plain film. Use what you have.
- [32:54]
A
Now. A quick word from one of our sponsors, Northern Health. Looking for more than just a shift? What if your next move gave you adventure, balance and a team that has your back In Prince George B.C. northern Health is hiring emergency physicians, physician assistants and nurse practitioners to join a high performance emergency department with over 54,000 visits a year, full specialist support and a collaborative team environment. Think short commutes, affordable living and world class hiking, biking and winter sports right outside your door at the center of the province. Flexible scheduling, competitive compensation and real work, life balance included. Ready to make an impact and actually enjoy where you live? Visit careers, NorthernHealth CA and join the emergency team in Prince George today. I want to now move on to a sort of top to bottom fracture of the face approach and we can talk about all the physical exam findings and such that are going to be key to helping us decide what to do with these patients. I like to think of the facial bones in three groups essentially, so you could call it the rule of threes. It's upper, which includes the bone, the orbital bones, middle is maxillary, nasal and zygoma and the lower is the mandible. So let's start off with the frontal bone of the frontal sinus. So this is the top third of the face, the forehead. Jeff, I know these are not very common, but when we do see these, what are sort of the big red flags clinically? What are the features of these kinds of fractures and what do we need to do with them?
- [34:29]
C
So we see these fairly commonly just because we, you know, we're regional centers. So I'm sure Andrew sees them quite frequently, too. So, of course, the concern with a frontal bone fracture is the brain. And the main clinical sign that there's something going on, something needs to be addressed relatively urgently is CSF rhinorrhea. So patients will present with the usual sort of profile of facial fractures. Swelling, bleeding, hematoma, usually periorbital. You know, they could have raccoon eyes as a result of the basal skull fracture that is continuous through the posterior wall. Basically, what you're trying to rule out is whether there's been a breach of the intracranial space. And the way to do that is when you see those clinical signs, obviously, is to get that head CT that we've been talking about to ensure that there hasn't been a fracture through the posterior wall of the frontal bone or through the floor of the frontal sinus, because the floor is where the frontal sinus drains. And if the floor is disrupted, and that usually goes along with nasorbital ethmoid fractures, which we're going to talk about, if the floor is disrupted, that's also a surgical problem because that means the sinus is not draining properly. So posterior wall and sinus floor, posterior wall of the sinus, frontal sinus, and the sinus floor are the things that need immediate assessment by neurosurgery, craniofacial or maxillofacial or plastic surgery.
- [36:01]
B
I think it's just worth repeating, Anton, to what Jeff just said as emerged docs, I don't know that we're always taught the difference between the. So the anterior table and posterior table. And it's not just all one frontal bone. There's distinct differences in the subsequent management of that. And so, you know, an anterior table fracture is not a big deal cosmetically. Maybe it is, but if you do, I didn't know about the floor element of it, but certainly the posterior table, if there's disruption there, that's a very different approach than somebody that could go home with just an anterior frontal bone fracture.
- [36:36]
C
A good trick for the CSF rhinorrhea confirmation is to ask the patient to lean forward and their cs, if they have CSF rhinorrhea, it should come out like a faucet. It should be either a very drippy faucet or a continuous faucet. So if you're wondering, just ask the patient to lean forward and see if they actually start dripping. CSF rhinorrhea. That's a good test. The floor is, if you imagine the frontal sinus from a sagittal CT view, it's like a triangle. So there's an anterior wall, there's a space which is the sinus itself, and the posterior wall, which is extremely thin. The anterior wall is, is thicker as a kind of protective measure. And the bottom of the triangle is the floor. And the nasofrontal ducts go through that floor. So nasal orbital ethmoid fractures often will disrupt the nasofrontal ducts and cause potential long term problems like mucoceles, mucopioceles, sinus obstruction, et cetera. So that is something that we need to know about.
- [37:37]
A
So frontal bone fractures are not all created equal. We really need to be careful about the floor and the posterior aspects. And so if you do have a patient with CSF rhinorrhea, that's someone who you need to think about those more dangerous diagnoses, and that's what you need to look for on ct. Let's move on from frontal bone, frontal sinuses to orbital fractures. Now, in episode 107, we dedicated the entire episode to ocular trauma. So we're not going to get into all the details of hyphemas and retrobulbar hematomas and orbital compartment syndrome and vitreous hemorrhage and all of that. But I do want to zero in on orbital blowout fractures, which are sort of the classic emergency orbital injury in terms of the bones. So, you know, the typical story we hear is a baseball to the eye. And of course, besides, one of our primary concerns being a retrobulbar hematoma that requires an emergency lateral canthotomy. The other thing that we need to think about is extraocular muscle entrapment. So, Jeff, could you just run through for us how you assess orbital blowout fractures and the mechanism of diploplia, how it's actually managed surgically, and how quickly these patients need to be seen by ophthalmology and. Or you.
- [39:00]
C
Right. I mean, the assessment, again, always thinking about associated injuries. Right. So the globe is really the critical thing. And visual acuity needs to be assessed before anything else. Extraocular movements will, will elicit the diplopia that Results from a mechanical impairment, as opposed to monocular diplopia, which may be a retinal issue. So extraocular movements, gross visual acuity, and then looking for the actual position of the globe, looking for global dystopia. So the globe can be actually moved in any which way, including pushed outwards exophthalmus or proptosis enophthalmus, which is the most common thing that we see with orbital floor fractures and medial wall fractures, and hypoglobus, which is the globe being downwardly displaced. And that's usually a result of a loss of support of the actual floor directly under the equator of the globe. If you imagine the globe being kind of sliced in half in a coronal sort of situation right underneath that midpoint, if you lose support of the floor, it will actually go down. One of the things that will tell you if you're not 100% sure of whether there's global dystopia, one of the clues is what's happening with the eyelid. So if it's a low energy blunt trauma, you may not see that ginormous amount of swelling. That makes it impossible to assess where the eyelid is, because everything's closed and everything's shut. But if it's a punch to the face or something, the patient may have ptosis. Ptosis is one of the signs that the globe has been retropulsed backwards and there's not enough support for the lid to be held upward. So ptosis is one of those clues that there might be something wrong with the position. If that's the case, tell the patient to look upward to the ceiling and look from below. The easiest way to determine the position of the corneas relative to each other and relative to the zygomas is from below. Everybody looks from above, but it's very hard to determine because of the brow. And if somebody's, you know, got a nice, strong brow, it's even more difficult. So have the patient look upward and look from the patient's chin up and see the position of the corneas to see if there's actually any displacement on the side that's been injured. And you'll see it relative to the position of the zygoma. If there's a lot of swelling in the zygoma, if they've had an associated malar fracture or a zygomatic fracture, it might be hard to tell. If you have a hertel exoff thermometer, that would be impressive. That would be the way to be sure of it but usually you can get a sense of significant enough thalamus, which is anything sort of 3, 4, 5 millimeters of retro displacement of the globe. So if you see that, there's a very, very strong likelihood that the patient has an orbital floor fracture. Orbital floor, medial wall fracture. And there may be an associated zygoma fracture. There may be an associated NOE fracture. Those are that constellation of those three often go together. Especially the higher the energy of the trauma, the more likely you'll have more than one of those.
- [42:12]
A
Okay, great. I guess this would be after the C spine is cleared.
- [42:16]
C
Yes, absolutely.
- [42:18]
A
You don't want the patient to look up at the ceiling.
- [42:20]
C
Thank you for that disclaimer. And infraorbital nerve numbness. Very strong positive predictive value. There's probably been an orbital floor fracture if there's V2 anesthesia.
- [42:33]
A
Great. Okay, so diplopia, you want to look from below if you can, if you've cleared the C spine to see any differences in where the cornea is sitting and if they have decreased sensation in the infraorbal nerve distribution of the cheek. So that would be an orbital blowout fracture. Now, there's all kinds of different orbital fractures. You know, medial, lateral, there's the floor, which is the big one we've been talking about. Zygomatic, ethmoid. What do we really need to know? Which ones actually require urgent surgery, like within 24 hours, and which one can wait for follow up?
- [43:13]
C
So obviously, if there is a problem with the globe, those are the urgent. That's the subset of urgent surgical emergencies. So, for instance, if there's a retrobulbular hematoma and there's increased intraocular pressure, that's something that needs to be addressed immediately. If there's entrapment, the muscle can necrose within six hours. Usually with an orbital floor fracture, it's the inferior rectus muscle that's trapped within bone, and that can decrose within six hours. So that's a surgical emergency. There's another condition called impingement. Very hard to differentiate between impingement and entrapment. But if you just have a shard of bone that's sticking out of the floor, the muscle can actually kind of get hooked up on that bone. That's impingement. It's not necessarily as much of an emergency. And that actually you need radiology radiographic evidence to show that it's not actually entrapped, but rather impinged. You have a little more time, but it's still something. Obviously, the sign is the same as the primary assessor. You're going to see an impairment of ocular motility. In your mind, it could be entrapment. You might as well think it's entrapment and call somebody immediately. So those would be the situations that are urgent. Other injuries where there's actually a loss of volume within the orbit, where there's a displacement of volume through the orbital floor, and there's global dystopia. Global dystopia, anophthalmus, hypoglobus, hyperglobus. Those things are not urgent. Those can wait. And we often will wait for swelling to resolve one or two weeks to ensure that the patient, first of all, is truly enophthalmic. Because sometimes it's an optical illusion. If the zygoma is very swollen, it almost looks like the patient's enophthalmic, and they're not. So we'll often wait, give it a week or so before we actually operate.
- [45:04]
A
So, okay, great. I mean, and in terms of displacement, I mean, you know, sometimes you think, oh, there's like, you know, 5 millimeters of displacement of one of the orbital bones. You know, that just would worry me. But it's not really much of a worry. The displacement doesn't. It really is. Comes down to entrapment than what the globe's doing.
- [45:22]
C
Correct. In fact, the bigger the hole, the less likely it is for the eye to be injured or entrapped. So in some sense, the more time you have. So a big hole is not going to grab onto the muscle. It's, you know, the white eye syndrome or a small hole or a small fracture that may actually more likely result in entrapment.
- [45:45]
A
Fantastic. That's, I think, a great sort of just overview of what really requires surgical attention in terms of fractures of the orbit.
- [45:54]
B
The one thing that sometimes comes up on the radiology reads that might and Jeff could weigh in, but would be whether if it's just some of the fat around the orbit that will herniate through and not the muscle. And it'll often be commented on that it is. It involves the muscle. And obviously you want to ensure that, then you've done an exam. But if it's just the fat, those are ones that in my practice, I'll just send as an outpatient, you know, assuming that they have no motor dysfunction or no significant, you know, paresthesias or anything. But I don't know how that differentiates on a surgical.
- [46:28]
C
We've sort of shied away from using radiology as indications for surgery. It really is based on your clinical assessment. If the patient doesn't have entrapment, and even if they do have some global dystopia, we will wait, let the swelling settle down, ensure that they truly do have enough thalamus before we operate. So the radiologist will often comment that the muscle is herniating into the sinus. I generally don't read those reports. Sorry. With all due respect to radiologists out there, some of my best friends are radiologists. Just wanted to add that.
- [47:18]
A
So just a quick summary here. What do you need to remember on your next shift? When you see a patient with a blow to the eye and you're thinking orbital fracture, first, don't focus on the fracture, focus on the eye. The important parts of the assessment are visual acuity, pupillary exam, globe position and extraocular movements. Ask yourself, is there a globe injury, is there orbital compartment syndrome or is there extraocular muscle entrapment? Those are the vision threatening emergencies. So if the patient has restricted eye movements, diplopia or signs suggesting entrapment, assume entrapment until proven otherwise and get urgent specialist involvement. Muscle entrapment can lead to ischemia, necrosis within hours, making it one of the few true surgical emergencies in orbital trauma. Look for clues to an orbital floor fracture, infraorbital nerve numbness, enophthalmos, hypoglobus, ptosis and globe asymmetry. A useful pearl is to have the patient look up and assess globe position from below rather than from above after the cervical spine has been cleared, of course. What about CT findings of orbital fractures? These can look impressive, but bigger findings are not necessarily more dangerous. So large fractures, herniated orbital fat and impressive looking bony defects are often less important than the clinical exam. In fact, larger fractures are often less likely to trap the muscle. Surgical decisions are driven primarily by vision, ocular motility and globe position, not by the size of the fracture on imaging. Let's move on to the mid face and talk about nasal fractures and all the other mid face fractures. Liora Sommer gave us a great EM quick hit segment on nasal fractures where he talked about why imaging is actually rarely needed in the ED for isolated nasal fractures and that obviously displaced fractures should be reduced in the ED because they're actually pretty easy to reduce. And of course he talked about septal hematomas. I want to dig into septal hematomas a little bit more because they can actually be easy to miss and I personally don't have much experience draining them. So I want to talk a little bit about how to drain them as well. Andrew, first, why do we care about picking up septal hematomas and dealing with them quickly in the ed? And then we can talk about how to actually recognize them.
- [49:44]
B
Yeah, so what ends up happening is you can. The patient then is predisposed to necrosis, ischemia, they can develop infection, some abscess formation. So you're basically just getting separation of the tissue from the underlying septal cartilage because you have a hematoma there. From an emergency medicine perspective, at least, it should always be in your notes. I think that it can often be missed where we just look, okay. The patient looks like they, you know, the nose is midline, they have some tenderness. We assume they have a fracture. But doing actually, you know, a dedicated exam to examine within the nostril is important and should be done as a matter of practice. In all instances, I think, is one thing that just needs to be re emphasized. I don't find that they're as common. Even as noted in the literature. They kind of quote 1% or something like that. But I think, you know, it's like any hematoma, they're fluctuate. You can put some vasoconstrictor in and if it doesn't resolve with that, then it's probably not edema. You obviously can palpate it and sort of assess symmetry between the other side and then you make your sort of best judgment, guess that you think that that's what it is, and then go ahead and drain it if you identify it.
- [51:00]
A
Yeah. I think it is sometimes a bit tricky to determine whether it's actually a fluctuate mass or whether it's just edema because sometimes they've just been punched in the nose and there's so much swelling. So it is worth actually sticking your finger up there and palpating it to see if it's a septal hematoma. And then for draining it, is it just like draining a little abscess? You just put a. Yeah, I'll just
- [51:21]
B
put some pledges of lidocaine with EPI in and then, you know, leave it for a few minutes, come back. I may. If I'm sort of not certain, I might just use a needle aspiration first to see if I'm in blood. I guess there's a possibility that's already clotted and you won't be able aspirated. So you can make a small incision. I mean, I guess if I get it wrong, it's going to heal fairly quick. You know, it's mucosal tissue. So making a small incision with a scalpel I think has big upside to the patient if you get it right. And if you aren't right and you cut into edematous tissue, you're just going to have some bleeding and you can control that. But I'll be honest, I don't see them subsequently. So Jeff might have some insights on what that actually means for the patient longer term.
- [52:11]
A
Jeff, any comments on septal hematomas?
- [52:14]
C
Well, first I would agree with Andrew that they're really rare. They're much, much more rare than you would imagine from how much is talked about them. I guess they are sometimes difficult to differentiate from edema. Especially if there's ecchymosis in edema could look exactly like a septal hematoma. And I agree with you Andrew, there's very little downside to sticking a needle in it. Most of the time they are clotted and you do have to make a small incision and then express it with digital pressure or with a Q tip, just try and milk it out. But there's little downside. If you get it wrong, they will heal and you just pack the nose anyway and that'll stop the bleeding. So I agree with everything.
- [52:54]
A
Great. Now I had just mentioned that, you know, we talked about how if someone has just an obvious nasal fracture that usually you don't need imaging at all. But I'm sure listeners are thinking, well didn't they say at the top of the podcast that pretty much everyone needs a ct? So I just want to talk a little bit about that, you know, because, you know, where I work in a community hospital, we see lots of people who get hit in the nose. Many of them don't even have a fracture. The ones that do have a fracture, I can't remember the last time I saw one who had, you know, a complex mid face fracture. So any tips or tricks like when is your threshold specifically for someone gets punched in the nose? You know, when would your threshold be for imaging there? Because and just in the context of Dr. Sommer had given a really good argument why very few of these patients actually need imaging in the ed.
- [53:46]
C
So let me qualify my previous statement about CT scans. I don't consider nasal fractures, facial fractures. That could be part of the problem and that's my fault. They certainly are facial fractures, but they're so minor in the scheme of facial fractures that I would agree they generally a simple nasal fracture does not need imaging. In fact, when we see nasal fractures and they are imaged, I don't even look at them. I look at the patient clinically. So when do you decide that this is not just a simple nasal fracture, but it's a nasal orbital ethmoid fracture or there's an associated orbital fracture, et cetera, You've got to go on your clinical judgment. The first thing to look at is, is what do the patient's medial canthi look like? Do they have telocanthus? Are the medial canthi displaced? Is there periorbital ecchymosis? And then use your basic clinical physical examination skills to rule out other fracture sites. And that's point tenderness. Where you would expect a nasorbital ethmoid fracture, which is the inferior orbital rim, the nasofrontal junction, and. And somewhere along what we call the medial buttress of the maxilla. So somewhere between the teeth and the bottom of the nose, there should be some fracture to make that diagnosis. Three points of fracture. If those are all clear and the medial canthus does not look displaced, there's no periorbial ecchymosis. You've got a simple nasal fracture. You don't need to image the patient.
- [55:21]
A
That's fricking gold. That's great. So three points. I just want to review that. Could you go over those again?
- [55:28]
C
So basically, so if you imagine. So the way we think of facial fractures, which I think is a useful way for all clinicians, as opposed to the way the textbooks show them, the four different levels, all that sort of thing, think of the face as a three dimensional puzzle, and the pieces are the zygoma, the nasal orbital ethmoid, and the maxilla. Every facial fracture, including Le fourt fractures, are combinations of those, what we call complexes. They all break pretty much in the same points to dislodge them or dislocate them from their attachment to the other complexes and the skull base. So for the nasorbital ethmoid complex, which is what we call it, complex being a piece of the puzzle, they break from the frontal bone, okay, at the junction of the nose and the frontal bone, they break at the inferior orbital rim at its junction with the zygoma. And they break from the maxilla at its junction with the maxilla, which is right at the piriform, right where you imagine the nose attaches to the maxilla. Those are the three points that must be broken for the nasorbital ethmoid complex. Again, piece of the puzzle to actually displace. So if there's no tenderness along that medial buttress, you can feel where the Piriform opening is. It's right along there. If you feel right along your nasal cavity, you can feel a ridge. That's that ridge. If there's no tenderness along the inferior orbital rim and there's no tenderness at the nasofrontal junction, it's highly, highly unlikely. You have a naso orbital ethmoid fracture and you probably just have a simple nasal fracture.
- [57:15]
A
Fantastic. Again, it comes right down to the physical exam there. And that's so important because I know that I have not imaged hundreds of people with nasal fractures. And my guess is that I probably missed some subtle facial fractures. If we're considering the nose, not part of the face, That's a bit about nasal fractures, nasorbitoethmoid complex fractures. Let's talk about lefort then. So, Jeff, you just had given us this great approach to mid face fractures in general. And of course, in the textbooks we read about LeFort fractures and that, you know, LeFort 1 fractures don't need to be transferred and LeFort 2 and 3 fractures do need to be transferred. What do we need to know about lefort if anything? Or should we just be using that great three point system that you just explained? And then which of these mid face fractures need emergent surgery, urgent surgery, or they can wait a week or two?
- [58:25]
C
Yeah, so I'm going to just go over this concept one more time because I do think it will simplify management algorithms as well, as opposed to just trying to remember, where was that LeFort 3 level? Where was that LeFort 2 level? So again, first of all, it's very rare for trauma patients to have a Pure LeFort 3 or a Pure Le Fort 2 or a Pure LeFort 1. These are high energy blunt trauma injuries. They don't break according to the textbook. Okay? So when they do break, they break according to those puzzle pieces, those three dimensional puzzle pieces I just mentioned. Zygoma, nasal, orbital, ethmoid and maxilla. Okay? And if you think of those complexes, the zygoma, where it attaches to the maxilla is the suture line between the zygoma and the maxilla, where the nasorbital ethmoid attaches to the other complexes. That is the zygoma and the maxilla are the suture lines. This is what Rene Lefort discovered when he dropped bowling balls on people's skulls to figure out these patterns, is that the face breaks along these patterns all the time. Zygoma, nasorbital, ethmoid and maxilla. So when you have a Le Fort 3, you're talking about zygoma, nasal, orbital ethmoid, and maxilla all breaking off the face, okay? Now, they may also break off of each other, in which case you have a 3, 2, 1. Okay? A LeFort 2 is the nasal orbital ethmoid with the maxilla breaking off the face. The zygoma is left behind. Le Fort 1 is just the maxilla breaking off of the face. So when you think of it now in terms of the complexes, as opposed to I can't remember what level goes where, then, you know, you treat a LeFort 3 according to what you're worried about about zygoma fractures, what you're worried about about nasorbital ethmoid fractures and, and what you're worried about when it comes to maxillary fractures, namely the eye, the brain, right? The medial canthus and the nasorbital ethmoid complex where it's sitting and the occlusion where the mandible is and the airway, right? So if you now only have a Lefort ii, you've got a nasorbital ethmoid complex and a maxilla broken off the rest of the face, you don't have to worry about the zygomatic. So I'm not worried about the malar and zygomatic displacement. I'm still worried about the eye because the nasal orbital ethmoid complex includes the orbit. And I'm certainly still worried about the mouth occlusion airway, because the maxilla is still broken. And at fort one, I don't need to worry about the nasal orbital ethmoid anymore. I don't need to worry about the zygoma anymore. I don't even need to worry about the eye anymore because the fracture level is just the maxilla. I've left those other two complexes behind. So when and if you make the diagnosis of these fractures, think of it in terms of those puzzle pieces. And those puzzle pieces will guide you as to what other functional, particularly functional issues are at hand. Okay? So a nasal orbital ethmoid, you've got lacrimal function, you've got the medial canthal function, the position of the eyelid, you've got the nasal airway, zygoma, again, orbit and the malar projection and the width of the face, etc. Maxilla, you've got all the airway issues and the bleeding issue, of course, because earlier we spoke about the internal maxillary artery. So the Maxilla at the LeFort 1 level is the one we have to worry about. So that's kind of an overview of how to think of the Le Fourt fractures. We. When you're deciding, does this need urgent transfer, it comes down to those elements. Is there an ocular problem? Doesn't matter if it's three or two. Is there an ocular problem? Need to transfer. Is there entrapment? Need to transfer. It's the same list of urgencies. Okay. Is there a medial canthal displacement? This is not a nasal fracture. It's an NoE fracture. It may be Le4 2, but it doesn't matter. You're thinking of that NoE fracture within the LeForort 2. Is there an occlusal problem? This is Le4T 1 or 2 or 3. Now I have to refer the patient for their occlusal problem.
- [62:48]
A
Fantastic. So it all comes down to the three pieces of the puzzle and what each of those areas will cause clinically that you can find just on physical examination.
- [62:59]
C
Correct.
- [63:00]
A
Fantastic. We're going to detail that in the show notes. I think that'll take most of us a few times to review to really get it. I have to say that after 25 years of emergency medicine, every time I go and read about lefort fractures, I forget it pretty quickly afterwards, and it's just never sunk in.
- [63:17]
C
I'll try and provide a diagram of that for the show notes.
- [63:22]
A
Fantastic.
- [63:23]
C
And I can just sort of list the concerns with each of those complexes.
- [63:29]
A
Perfect. So we've talked about the mid face. Let's go to the mandible now. And, Andrew, we get these a lot in the emergency department. The patient that I presented at the top said they just felt like their bite felt wrong. So when it comes to assessing for mandible fractures, how do you do it? Are you a believer in the tongue blade test? You know, that was, I don't know, 10, 15 years ago. There was an emergency literature article that came out that if you put a tongue blade in their mouth and ask them to bite on it, if. If you can break the tongue, the wooden tongue blade, then they don't have a fracture. And I understand that the sensitivity was pretty high for that. How do you assess for the possibility of mandible fractures?
- [64:11]
B
Yeah, I think you already alluded to, you know, malocclusion, though that could just be because they have teeth that are displaced too. So, you know, I think a good physical examination, I mean, is there just intrusion? All of the teeth have just fallen in. Well, then, of course, you'll have what feels like to the patient malocclusion. You can have just a strain of your tmj, and it'll feel off for a period of time until it kind of heals. But in the case of acute trauma, I think the presumption should be that there's at least some fracture that's happened somewhere, depending on where that then correlates with tenderness. So I would assume if it's an isolated shot to the jaw, my assumption is that they do have a mandible fracture until kind of proven otherwise. I think I do. I guess I have used the tongue blade test. Its relevance is maybe isolated to the patient that you're trying not to image at all, and you're trying to maybe reassure yourself that they don't need anything. So if a patient says they have no malocclusion, they can bite down, you know, they have some tenderness, maybe some swelling along the mandible, along the jawline. And the mechanism could be compatible with a fracture. And then they can bite down on a tongue blade. You can break it on both sides, and you got to do both sides because it is a ring. Then I'm somewhat reassured that the probability of fracture is low. It's not 100% the sensitivity reported in the literature. Its utility is really, when you're trying to say, I don't want to do any further testing, you're trying to exclude that. But that should go along with malocclusion or lack thereof. Otherwise, I think I would probably proceed with imaging in many of these cases if the mechanism fits.
- [65:58]
A
Okay, so that's. In terms of who to image. What about sort of red flag features that make you worry that there's a complication of a mandible fracture?
- [66:07]
C
I mean, so we alluded to the airway earlier. So once again, if you see something like a parasymphyseal fracture where the ring, as Andrew referred to the mandible, is a ring, you know, the ring has been disrupted in a segment that has lost its stability. That's something that needs to be considered. And potentially we talked about the. The towel clip in the tongue for something like that. Loose teeth. Again, occlusion is really kind of the. The first screen to determine whether there's either a mandible or a maxillary fracture. But as Andrew also alluded to, that could just be teeth, or it could be a dental alveolar fracture. One of the tests that I find is quite useful, actually, are the pressure tests, both for maxilla and for mandible. So because it's a ring, if you put pressure on the angles of the mandible if there's a disruption anywhere along that ring, you put medial pressure on both sides, you're likely to elicit a significant amount of pain. I have never used the tongue blade test. I think this is a fairly reliable test. And particularly if there's parasymphoseal or symphyseal fractures, you'll actually see the teeth move. You'll see them open. Similarly for maxillary fractures, pressure just under the anternasal spine. Unless, again, they have alveolar. Dental alveolar fractures in that area, which then you would avoid this. But otherwise, if you have pressure on the anterior nasal spine, you'll find that there may be some mobility. You usually have to stabilize the head under the orbits a little bit first. Otherwise you're just moving their whole head and they'll feel a lot of pain. Sometimes they'll even feel it along the line of fracture. And you can make your Le Fort fracture diagnosis without looking at the ct. But those I find are very good screening tests as opposed to putting anything in their mouth. I think that's in my mind, not necessarily that specific. Just because pain is such a subjective thing. And if somebody's just been, like Andrew said, if they've got trismus, if they've got masseteric bruising or hematoma, that's going to hurt just by clenching their teeth. So I try not to get them to clench their teeth. I just put pressure on the angles of the mandible. Other than the airway issue with teeth and with an unstable segment, the only other thing I would say is tissue loss. Because every mandible fracture in the tooth bearing portion, that is to say from angle to angle, is theoretically open. Because the teeth are open. There's a communication between the roots of the teeth and the bone, and there's a disruption in the gingiva at that point. But if there's a significant loss of tissue, particularly if there's necrotic bone or fragmented bone in the region, then the risk of infection goes up significantly. So those are a little more urgent than somebody who, you know, comes from your bar fight has an angle fracture. You can't really see any opening on the inside. You know, there's communication with the teeth, but that I wouldn't consider a truly open fracture. But if it's truly open and there's a defect of tissue and you can see, you know, sometimes you'll see their teeth like this, and you can actually see into the. The gaping hole of their gingiva, that's a little more urgent. And that I would expect to get a call, you know, within a 24 hour, 12 to 24 hour period about that patient.
- [69:34]
A
Great. So two things you do in terms of palpating the face. The one was you just go at the angle of the jaw bilaterally and push inward and you can actually sometimes see the teeth moving there. The second one, you said the nasal spine, which I don't think any emergency doctor knows what a nasal spine is.
- [69:51]
C
So between the bottom of the nose and the two incisors, your two front teeth, that bone there, which is the maxilla, if you press on that, bones kind of stay above the teeth, you'll also feel a little bit of a bony protrusion. That's the anterior nasal spine. If you press just below there, you will move the maxilla if it's unstable, and you'll elicit the pain and you may even elicit movement if you stabilize the rest of the skull.
- [70:21]
A
Okay, great. Those are some great physical exam pearls. Excellent. Let's take a little break to hear
- [70:28]
D
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- [71:22]
A
And I just want to clarify, with the open fractures of the mandible, are there any other fractures of the face that we need to consider open? And if we do consider them open, how does that actually change our management? Do they all need antibiotics? What do we do with those?
- [71:37]
C
So what I was referring to is the tooth bearing mandible. The tooth bearing segments of the mandible are kind of always open even when they're not injured, because there's bacteria that live in the alveolar bone and around the teeth. So for the mandible to be truly open in my mind to the point where this becomes an emergency or more urgent than, you know, usually we treat mandibles within days, a week, sometimes there's no evidence that they need to be treated urgently or emergently. But if somebody has had either a high energy penetrating trauma or very, very severe high energy blunt trauma where their mandible is really truly exposed, and particularly if it's comminuted, that becomes urgent. Other bones are not the same because they don't live in symbiosis with the flora of the mouth normally. So if you see open, truly open fractures of something that's normally covered by soft tissue and skin, those are usually sterile environments. Those are open injuries and they need to be treated semi urgently, I would say, or urgently. The vascularity of the face is very good. So it's not quite the same as an orthopedic or open injury where they really want to get the patient in within six hours, get it washed out, et cetera, unless it's a very highly contaminated wound or farm injury, et cetera, usually we have a little bit of time. And the other thing is those wounds, we have no problem closing those wounds if they're closable, suturing them up until we can get the patient to the operating room. Because the face is a bit of a different situation just because the vascularity is so high. Those patients should get prophylactic antibiotics. But certainly if you know the patient's been admitted, we're going to take the patient to the operating room within 24 hours. Let's say with this very wide open gunshot wound of the mandible, that's a patient you want to put on prophylactic antibiotics right away. And they stay on those until they're taken to the operating room.
- [73:37]
A
Just a quick break to remind you that tickets for the online virtual EM Cases Summit November 19 to 24 first go on sale through the EM Cases Summit website on July 14 at 10am Eastern Standard Time. We have 30 EM cases, guest experts giving talks, all followed by audience questions, moderated by myself, plus virtual simulations. Four symposiums, one on eFlow, another on rural EM, another on AI in emergency medicine, and another on global EM. We have three pre summit courses, the Heart CCG course, Synapse Neurology course and the casted orthoradiology course. Last time we had more than 500 EM cases. Listeners from all over the world join us. It's interactive, it's fun, it's a great way to rejuvenate from your shift work. So head over to emcasessummit.com to grab your tickets and I hope to speak to you there. I think we've covered everything we need to know about fractures. I want to move on to soft tissue injuries and let's just break this down into four soft tissue injuries that we see that might need plastics. Involvement that we need to know about in the ed. First is eyelids. The second is lips. The third is the scalp, forehead, galea, the third, and the fourth is facial nerve. So let's cover those four. So let's start with eyelids. So, Jeff, what do we need to know about eyelid injuries? How should we deal with them in the emergency department? How should we identify the ones that need plastics or ophthalmology urgently? What can you tell us about eyelid injuries?
- [75:22]
C
Sure. So the associated functional consequences are always the thing to consider. Is there an ocular injury? First and foremost. So rule that out. Is there a lacrimal duct injury or the possibility of a lacrimal system disruption? Those are really the important things to think about and to consider. Not that you would necessarily be cannulating the lacrimal system or fixing the ocular injury, but it needs to be identified. If for no other reason than if there is a potential lacrimal injury, you probably do not want to be suturing up the eyelid because there's potential of damaging or disrupting and even obscuring the ability of the plastic surgeon or oculoplastic surgeon from finding and cannulating the lacrimal duct, the canaliculus, et cetera. So if you stick a suture through it and it disrupts it, it makes our job harder because then you've introduced edema into it. It's more much harder for us to put a probe through it to find it. So in general, if it's medial, and it looks like it may be involving the canaliculus, the canaliculi, there's a superior and inferior one or any part of the lacrimal system, I would just leave it alone and at that point get consultation from an oculoplastic surgeon or a plastic surgeon. If it's lateral, it's not as much of a consideration. There isn't too much within the lid itself. If it's a simple laceration through skin, even orbicularis, you do not need to repair the orbicularis. We often take out orbicularis and our cosmetic procedures and don't put any sutures in it. It's the levator that is the problem. The levator palpebrae is the muscle that's deep to the orbicularis, deep to the orbital septum, in fact. And the fat, if it's lacerated, then you're going to end up with ptosis, and that does need to be repaired. So if the patient Presents and they have ptosis, they can't move their eyelid. They can't open their eyelid. They may either have a blunt disruption of the attachment of the levator, which is actually quite common in orbital fractures as well, and that needs to be repaired, or if it's sharp trauma, they may have actually lacerated their levator palpebrae muscle or the aponeurosis, and that needs to be repaired. So again, if you see a patient, they have ptosis, they're not able to move their eyelid. Probably best just to leave it. You can always close skin, but don't try to repair any deep structures. Skin can always be opened. So if it's a matter of time and you want to keep the wound clean and not contaminated, if you're not comfortable closing the skin, put a saline soaked gauze on it. Again, it's the face that can last for hours and hours without any concern about infection. Or if you feel that you're comfortable doing it, you can stick a couple of tacking sutures in just to get the skin closed to preserve underlying structures. With the exception of the region of the cannuliculus, I wouldn't even close skin over the cannuliculus because again, the risk of injuring it and making it harder to cannulize is too great. Other than that, full thickness injuries or lacerations of the eyelid is a question of aligning structures. That's probably something you want to leave to somebody with specialized expertise to be able to do that and align it. But skin closure shouldn't be a problem. Orbicularis closer should not be a problem. Again, you don't need to put sutures in the orbicularis defects, whole different story. Dog bite, taking a chunk out of the eyelid, saline gauze, something to protect the globe, and coloplastics or oculoplastics, that's something that you should not be closing because that will require replacement of the defect.
- [79:08]
A
Great. And in terms of the timing of when these do need to be repaired, the ones that you're not going to be touching and that you refer to just generally, when's the best time to repair those?
- [79:18]
C
Again, infection is not a huge emergent concern. I would say you'd want to get those patients seen within a 24 hour period, you know, next day clinic, as many community hospitals have a plastic surgery clinic, the next day. As long as they're dressed or tacked closed, that should be fine.
- [79:37]
A
Fantastic. Let's move on to the scalp and forehead. And before we get into the details, of all the layers and everything and what needs to be closed where. Andrew, when you have a polytrauma patient, we all know that we want to close any scalp bleeds before they go to CT because they can bleed out. What's your sort of go to in terms of getting that scalp bleed closed?
- [80:04]
B
Jeff's already alluded to just the vascularity of the face. So these do bleed or can bleed a fair amount. And particularly patients that are on anticoagulation, they tend to bleed a lot more and you'll notice come back 10 minutes later and it's bled much more than you expected. Putting in lido with EPI to try and get some vasoconstriction and then depending on the location, you know, if it's non cosmetic location, I'll use staples because you can close it quite quickly. Also, you know, to Jeff's point earlier, you can always just remove the staples. Like if the goal is to try and get the patient to CT and you're just trying to get hemostasis and it's a resuscitative maneuver, I might, you know, in an area where I think it's less cosmetically a problem, I may still put staples in for a quick hey, we just need to get this person to CT for subsequent. Or the staples can be removed later, but otherwise, yeah, some, some degree of good direct pressure with, with sutures is, is quite reasonable. And then when I'm doing my exam in the patients that are non emergent and we're now trying to, you know, have a good look and see, I'll look to pay attention to whether the galea is disrupted and those do need to be repaired because you can get a subgalia hematoma that that forms. So if you have a big gap that just requires closure with, with usually VICRO or Vicral rapid or something that will hold the galea together so you reapproximate it. It doesn't need to be perfect but. And you may do a layered closure, but that galea should be re approximated in some way. So if you see skull and then you do see galeo disruption, then that should be closed.
- [81:36]
A
Fantastic. Yeah, I want to talk a little bit more about the galea. So there's like five layers of scalp. Right. And if you could just describe for us when we know that the galea has been disrupted and then how best to repair it so that we don't end up with a massive hematoma.
- [81:56]
C
Yeah. So Andrew already alluded to the fact that if you're seeing skull, the Galea has been disrupted. That's a pretty sure sign. So in a trauma situation, I mean, we go through the scalp all the time when we're doing big facial reconstructions and we always repair the galea. In a trauma situation, it may be hard to identify the galea, particularly if it's blunt trauma. The galea sometimes just bursts and you may have strands of galea. It's a white layer. The mnemonic that I think you're referring to is the skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue and periosteum. So the galea sits right above the loose areolar tissue. And that makes it actually very easy to find because you can just stick your finger under the scalp and if you can sweep the scalp off, you're in that loose areolar tissue and you're just underneath the galea. So that's one way of identifying whether or not there's actually been a disruption. If you can stick your finger in the wound and you can sweep the scalp off very easily, the galea has been disrupted. Everything above that galea doesn't come off easily, it's stuck. So that's one way of determining whether or not the galea has been disrupted. The other way is to visualize it. It's a white, thick fibrous layer. You can usually see it again in a trauma situation, might not be that easy. In a controlled surgical situation, we cut it so we can see a nice line. If that's the case and you're really having trouble finding the galea, you can take full thickness scalp sutures. In this case, staples won't work because they won't apply enough hemostatic pressure to the galea. And the vessels are coming through the galea. That's the other reason, important reason to close it and why it prevents subgal hematomas because the vessels are actually coming just outside of the galea. But you can take a big, even an O silk or a number one, anything. You can do anything, ethibond, ethylon, and just put it full thickness through all of those scalp layers, stick it right under until it passes right underneath the galea and use those even as a continuous suture, like a baseball stitch, just to get hemostasis. That's perfectly fine. First of all, if it's hair bearing scalp, nobody cares about the cosmesis anyway. If it's not hair bearing scalp, we can always redo it when the time comes. So if you're just trying to get hemostasis, get the patient into the CT scanner. That's the way to do it. If you can't find the galea, sometimes it's a little bit difficult to find.
- [84:27]
B
And it's tough too, because it's a fibrous tissue. So, yeah, I like that. And that's what I've done too, is what Jeff just described. I'll just take a bite and, you know, you've gotten it with the suture because it's tough. It's like going through fascia, I guess.
- [84:41]
C
And don't listen to all your plastic surgeons that taught you in your PGY1 or clerkship. Just take a big bite 5 or more millimeters from the skin edge and just go all the way straight through, right through the entire scalp. You just want to get hemostasis, and that's all fixable down the road.
- [85:05]
A
So in terms of soft tissue injuries, we've talked about eyelids, we've talked about scalp and forehead. The next thing I'd like to talk about is the facial nerve and perfect parotid duct. And when they're injured, and I gotta be honest, I can't remember the last time I picked up a parotid duct injury. My guess is that they're picked up later. How do we assess for parotid duct injury?
- [85:28]
C
Parotid duct is challenging, and as you said, it's often missed. It's often hard to diagnose, especially when there's a messy wound where you can't really see anything, or a bloody mouth where you can't even see Stenson's duct or see if any saliva is coming out.
- [85:44]
B
Out.
- [85:45]
C
You can push on the area, the preauricular area, to see if saliva comes out of the wound. You can look inside the mouth to see if it's coming out of Stenson's duct, out of the papilla. And if that's the case, chances are it is intact. But really short of that, it's just a question of getting the patient stitched up. And if you're suspicious of it, getting them seen by entire. When should you be suspicious of it, really? When it just crosses the path of Stenson's duct, of the parotid duct. And essentially any laceration that's deep enough to go through the parotid. Cause remember, the duct is kind of between the. Just like the nerve is between the superficial and the deep lobe. So if you're seeing parotid gland, which is browner than fat, should be identifiable. And you're seeing a deep enough laceration, you should suspect it, particularly if it is Anywhere between the tragus and the commissure of the mouth. So if you imagine a line between the lateral commissure of the mouth and the tragus, anything in that zone that's deep enough to show you something deeper than fat, you should probably suspect that there may be a facial nerve injury and. Or a parotid duct injury, in which case you would send them off for referral to entire.
- [87:06]
A
Okay, great. So draw a line from the edge of your mouth to your ear to the middle of your ear. And if there's a deep laceration that goes beyond the fat, especially if you see brown, that's a parotid duct.
- [87:17]
C
Yes. Anything that crosses that line transgresses that line. There's a chance that something's happened there.
- [87:23]
A
Love it. Simple. All right, so we've covered eyelids. We've covered scalp and forehead. Galea. We've covered facial nerve and parotid duct. The last thing I wanted to talk about was lips. And, you know, we go on about the vermilion border. We know that we want to close that first and line it up nicely beyond the vermilion border. What do we need to know about lip lacerations? The particular questions that I always have in my mind are, which lacerations on the inside of the lip need to be closed, which ones don't, and then when do we need your help? When do we need plastics, you know, in the emergency department?
- [88:02]
C
So I think with regard to the vermillion, that certainly is important. One pearl, I think, is to ensure that you mark that vermilion before you put your local anesthetic in. If you're going to do this under local, the patient's conscious, and you need to put freezing in. Take a scalpel, take a 15 blade, and score the vermilion border on both sides of the laceration. Don't use marking pen, because chances are it will be rubbed off. So take a knife and just score the skin right at the junction of the vermilion border and the white line, which is the part of the skin that sort of blanches a little bit as it comes to the vermilion, right at that border. You want to make a little score on either side of your laceration so that after you infiltrate the area with local, and you should use epinephrine so it's going to blanch. You can still find the vermilion border because the common thing is you inject it, and then you don't know where the vermilion border went because everything is blanched.
- [89:01]
A
Great, Pearl. One Thing I've used is we have lidocaine, epinephrine, tetracaine gel in the emergency department let, and I use it all the time for lacerations. You know, traditionally it's only been used in pediatrics because we want to avoid poking them with needles. But I use them in adults too. I mean, I don't want to poke adults with needles if I don't have to either. I've used let with, I think success on lip lacerations before. And, you know, I guess the old thing that we learned about never using epinephrine on the lips and the tip of the nose and the penis. That's not a thing.
- [89:35]
C
That's not a thing anymore.
- [89:36]
A
Okay, good.
- [89:38]
C
That's not a thing anymore.
- [89:39]
A
So is that a reasonable alternative?
- [89:41]
C
Yeah, sure, if it, if it does the job, absolutely. I think it's always good to, to mark the vermilion border anyway just because, you know, things can change and your best bet at identifying it is before you start the procedure. So a little score with a knife and you're golden. The other thing I would say is a three layer closure. You do need to close the mucosa in a full thickness lip laceration. The more tension you can take off of the closure, the better because it's something that the patient's going to move, it's something that's going to have a lot of tension on it. So a good muscular closure, very important. I usually use like a 3,0 Vicryl, something resorbable in the muscle, two or three of those and then some resorbable gut for the mucosa. And then I usually use a nylon or a prolene for the skin side of the closure. Well, one of the other reasons to do the muscular closure is because one of the sequelae of lip lacerations that are full thickness that have gone through the muscle is a diastasis of the muscle and a notching of the lip. And that can actually affect oral competence. So one of the reasons to get a good muscular closure is so they don't get notching at the site of the laceration.
- [90:58]
A
Excellent. All right, so that's vermilion border. What about those lacerations that are inside? When can we leave lacerations inside the lip? And this is particular for kids because, you know, we have to go through a full procedural sedation. And if we can spare that. My general rule is, you know, if you can imagine a piece of food getting stuck in there, it needs to be closed. Otherwise you don't really need it closed
- [91:22]
C
or not even not even. I would say, if it's a pure mucosal laceration, if it's going to heal with a flap. So if there's actually a flap of mucosal tissue that's sort of flapping around and it's going to heal that way. Same with a tongue laceration, you want to tack that down, because otherwise they're going to have to get it resected eventually, because it'll survive and it'll live as a flap. And the other reason I would say is hemostasis. You know, the last, the size of the laceration, you know, probably is related to the hemostasis and the likelihood that some flap will be created. But yeah, in general, small superficial lacerations in the mucosa, they're going to heal very quickly without anything. If they're not bleeding and they're not flapping, then I would leave them.
- [92:07]
A
Great. Okay. So flaps close hemostasis. They just won't stop bleeding. You're going to close those. Great. So we have covered facial fractures, we've covered soft tissue injuries. So let's move on now to disposition and discharge instructions. So good discharge instructions, as we know, can prevent some bad outcomes. What are the sort of. Must include discharge instructions for patients going home with facial injuries in general, and then we can talk specifically about different fractures and soft tissue injuries.
- [92:51]
C
In the case of upper facial fractures, you want patients to be vigilant for any visual changes. They might get entrapped, they might get emphysema, intraorbital emphysema, if they sneeze or blow their nose. Which brings me to the other very important instruction, which is sinus precautions, which I'll talk about in a second. So any change in vision, any redness, worsening swelling, worsening pain, might indicate infection, especially if there's sinus involvement, if there's oral cavity involvement. Those are real possibilities. Possibilities. The patient should be made aware of all of that. As far as upper facial injuries, you want them to be vigilant for CSF leaks, CSF rhinorrhea, which we spoke extensively about, and of course, levels of consciousness issues. As far as the lower face, mandible, maxilla, there's not really too much that, other than infection that can really cause alarm or raise alarm bells. But the general rule is anything that might indicate infection or might affect level of consciousness and vision would be things to be aware of and to contact a physician immediately.
- [94:05]
A
So you had mentioned sinus precautions. Could you tell us exactly what you tell patients for that?
- [94:10]
C
Yeah. So the idea behind sinus precautions is there's a communication between their friends, fractured sinuses and the orbits when they're mid facial fractures, zygoma fractures, noe fractures. So I specifically ask patients not to blow their nose and to sneeze with their mouth open. And I actually kind of put the fear of God in them because when I see them subsequently, often referred from the emergency department, they may show up with intraorbital emphysema and raging orbital cellulitis, which, as you know, could be very dangerous with cavernous sinus thrombosis. And I'll say, have you been blowing your nose? And they'll say, no, no, just a little bit. So when that is conveyed by the emergency physician or by me, I often will say, you know, if you blow your nose even once, even a little bit, and you blow bacteria from your snot into your eye socket, you could develop a complication that will kill you. And that usually stops them from blowing their nose very slightly or at all. So sinus precaution is very important. Open mouth sneezes, no nose blowing. The other thing is to maintain, usually if they've got a maxillomandibular fracture of some sort, occlusal skeletal fracture, maintain a soft diet. I usually ask them to stay on a puree diet. So that's very important. Head elevation. Head elevation doesn't have to be extreme. It's only, and I actually say this to patients, keep your head above the level of your heart because it's really just for venous drainage. As long as, you know, 10, 15 degrees is fine. Those are really the main precautions.
- [95:54]
A
Fantastic. All right, I think we'll have a nice little list in our show, notes of those precautions we should tell patients before we discharge them home with a facial injury. Before we head to the end here, I just want to try and review and summarize which patients need to be seen now, which patients need to be seen within 24, 48 hours, and which patients you want to see in a week or two, once the swelling has settled down. And I know we've talked about, we've covered a lot of stuff, but if we can go through just sort of the different fractures and soft tissue injuries and try and summarize which ones. We really need to be picking up the phone to the plastic surgeon now. Which ones can be seen next day and which ones should be seen in a week or two.
- [96:41]
C
Sure. So top to bottom, and in a general sense, uncontrolled bleeding, obviously from a frontal sinus, frontal bone point of view, posterior table fractures, sinus Floor fractures, because they often are associated with posterior table fractures, anterior table fractures can wait days to a week afterwards, not a problem. They can be assessed and in fact are better assessed when the swelling comes down because we want to see what the cosmetic deformity is going to be. Nasorbital ethmoid fractures, better sooner than later, I would say within a few days, primarily because of potential lacrimal and orbital issues. Orbital floor fractures, if there's no entrapment and if there is no visual acuity or ocular concern, again, they can wait. They can even wait up to a week because we want to see them after their swelling has subsided and ensure that their ocular position is stable. Zygoma fractures, same thing. If there's no ocular concern, zygoma fractures can wait again. About a week is fine. Somewhere within two weeks. By two weeks. The reason two weeks is such a magical number for us is because bone starts to unite at about two weeks. And the younger the patient is, the faster that happens. So if we want to book the patient for surgery, we'd like to know within a week whether the patient's going to need surgery or not. But at the same time, we want the swelling to be down enough to know whether the patient needs surgery or not. So one week is really the sweet spot. As far as nasal fractures, again, we want to treat those, especially for a closed reduction of a nasal fracture. We want to get the patient somewhere within the 10 day range, you know, one week, 10 day sort of thing, just because, again, the bones are going to start to get sticky. Younger the patient, sooner the better. Septal hematoma should be drained immediately. Maxillary fractures, no urgency. But the decision to transfer a patient or to have the patient admitted is really based on the patient's ability to maintain nutrition and withstand pain. Because they are big fractures. To break a maxilla off, that's a high energy fracture. So if the patient's able to stay on a pureed diet, liquid diet, soft diet, maintain nutrition, maintain pain control, a maxillary fracture of the one fracture can go home, theoretically. Very often, though, they're not able to do that. And they'll need intravenous fluids and, and potentially pain control as well. Same with mandible fractures. We send mandible fractures home that are closed, as I mentioned, you know, not grossly open, as long as they can manage nutrition, pureed diet, mouth hygiene, which is, by the way, also good instruction to give patients. I usually suggest hydrogen peroxide and water, half and half, pour that into a big bottle or container that they have by their bedside, have a basin beside them, swish and spit every hour while they're awake if they can. That's actually a very good way to reduce the risk of infection and maintain their mouth hygiene. So if they're able to do that, they're able to manage their pain and maintain nutrition at home. Maxillary and mandibular fractures can go home in theory. They don't necessarily need to be admitted generally to be seen within a day or two. I would say for those just again because of planning and being able to get the patient into surgery within a reasonable amount of time.
- [100:12]
A
Jeff, if there were, let's say, three things that you wished emergency doctors would do that you find, say again and again in your follow up clinics you wish that they would do that they sometimes don't do, what would those three things be?
- [100:31]
C
You know, honestly I find you guys actually to be very, I'm not just blowing smoke. I find that the emerge docs that I deal with are very, very thorough. There's very little that they leave out. I would say the sinus precaution thing is probably the one. If I have a pet peeve, it's the one pet peeve that I have. It's not impressed upon the patient enough how serious that is. Probably conveying some sort of comfort in a way that for instance, the facial fractures that we spoke of that don't need urgent attention once again, things that don't involve ocular well being or health airways, et cetera, but the lower energy type of injuries that they don't need to be treated emergently. And in fact sometimes it's beneficial for us to see the patient after the swelling has subsided a little bit. And we're better able to assess that because sometimes patients come and they're bewildered and they're scared and they don't really understand that sometimes facial fractures are really not such a big deal and are relatively easily treated and managed. So that would be probably the only other thing I would say is convey to your patients when those facial fractures are not serious, convey that to the patients and make them understand that, well, you know, you may need surgery but this is not something urgent and you don't need to worry about and lose sleep over.
- [102:01]
A
All right, gentlemen. Well, we all learned a ton from, I certainly learned a ton from our discussion. If there's one thing you could leave our listeners with that they can take home and use on their next shift when it comes to facial injuries, what would it be? Andrew?
- [102:16]
B
Yeah, I think the most important thing is to do a good physical exam, and I do think that it needs to include the eyes and the ears because of the potential injury for these patients, and then remembering the concomitant risk of cerebrovascular injury, especially when there's significant trauma to the face.
- [102:36]
A
Thanks so much for your contributions to EM cases.
- [102:38]
B
Thanks for having me back. Antonio.
- [102:40]
C
Thank you. Ra.