Wet Reads Facial trauma: A look beyond the bones

Elderly female with head and facial injuries with diminished mentation & poor respiratory effort…

 

EMS calls in; they’re coming from the scene of a car wreck with an elderly female. The story is that she had run a stop sign and hit a tree, possibly without wearing a seat belt, in an old car with no airbag. She has head and facial injuries with diminished mentation & poor respiratory effort. The medics are unable to intubate her due to her severe facial injuries. The patient has a weak pulse, and they are bagging her with limited success.

On arrival, the patient is in extremis. She has obvious severe facial injury, with crush and distortion of nearly all of the normal landmarks. P 80, RR is maybe 8/min. You attempt an intubation, but no luck. Although there is not much trauma below the jaw, the nasopharynx is edematous and filled with blood and vomit. The on-duty CRNA arrives and the two of you together get her intubated with the help of suction, position, cricoid pressure and some luck.

Post-intubation her O2 sat’s are 96% on 100% oxygen on the ventilator. Your trauma exam shows intact BS bilaterally, normal heart tones, stronger pulses and improved perfusion throughout post-intubation. The rest of the trauma survey exam shows only the obvious facial and head injury. There is a left frontal hematoma and the massive facial crush with crepitation, subcutaneous air all through the mid-face. The globes — and pupils — are impossible to assess due to edema. She does not withdraw to painful stimulus in any extremity. The CXR shows a prominent mediastinum but no other major injury. The pelvis film and trauma ultrasound are normal.

Routine trauma CT scanning (head, c-spine, chest/abd/pelvis) is ordered — along with facial CT — and the surgeon called. Medical evaluation is also ordered to rule-out a medical cause of the trauma (e.g. acute MI). CT starts her imaging of the head, face and C-spine without waiting for a serum creatinine (thank you).

The facial CT is shown. What does it show?
see next page for results and discussion
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Severe facial trauma like this is rarely an isolated injury, and this case is no exception. This unfortunate woman had, it turned out later, subarachnoid traumatic brain injury and possibly an aortic tear. She also likely had an acute cardiac event which precipitated the injury.

The facial CT illustrates the severity of her trauma. At some point, labeling this CT is almost redundant. It is hard to find something that is NOT fractured. Start with the orbits on the coronal view (top). The globes are mostly intact, but with retro-bulbar air and multiple orbital fractures. Both coronal sections show the sinuses, nasal septal structures and parts of the sphenoid bone just shattered, with the whole mid-face crushed posteriorly and angled backwards (middle image).

The coup-de-grace (literally) is on the third image. As with facial fractures, it is the associated injuries that kill or disable you. In this image, fractures can be seen in both carotid canals in the basal skull (left one noted by arrow). Vascular injury to both carotids effectively disrupts the majority of critical cerebral hemispheric circulation. Very bad. This unfortunate woman died a short time later from her multitude of injuries. As a side note, you can see the limited patency of her nasopharynx in the region where the ET tube and OG tube (thank you for not placing an NG tube in this case) are located.

 

Even the somewhat hardened ER staff took this loss a bit hard. A sweet “little old lady” who met a painful and traumatic end, rather than a quiet death in her sleep in the years to come. But even in the worst cases, there is usually something to be learned — the best and toughest clinicians always take the learning point as a measure of solace to balance against suffering and loss.

Studies Show Good Outcomes Likely with Elderly Trauma Patients
Advanced age might increase trauma-related morbidity and mortality, but good outcomes are attainable when appropriate care is provided to those individuals with survivable injuries.

Inaba et al. demonstrated that the majority of elderly blunt trauma patients attain functional independence, but 20% still required home care 3-years after their injury. 

McKevitt et al. demonstrated in a case-control study that although older adult trauma victims were hospitalized significantly longer and sustained more complications with more hospital-to-nursing home discharges, 75% were functionally independent at 2 years.

Grossman et al. studied the “old-old” (over age 85 years) and found that octogenarians are less often discharged to home, but feeding and social independence could be maintained.

Based upon lower quality Level III evidence, the EAST guidelines offer the following predictors of increased mortality over age 65:  base deficit < -6, GCS < 8, trauma score < 7, or respiratory rate < 10.  Mild traumatic brain injury, either in isolation or in combination with multisystem trauma, is associated with increased mortality and worse functional outcomes.  Based upon these factors, some have advocated for age alone as a criterion to activation of trauma teams.  In the future, research on older trauma patients will benefit from standardized short- and long-term survival and patient-important functional outcomes. -Chris Carpenter, MD, MSc