Page 64 - JSOM Fall 2018

Facial Trauma Care in the Austere Environment

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Scott J. Farber, MD *; Rami S. Kantar, MD ;
Eduardo D. Rodriguez, MD, DDS 3

ABSTRACT
As the United States continues to increase its use of Special have incurred injury to the CMF region. Survival rates after
1,2
Operations Forces worldwide, treatment of craniomaxillofa­ sustaining an injury in combat are now greater than 90%. 3
cial (CMF) trauma must be adapted to meet the needs of the
warfighter. The remoteness of Special Operations can result Severe CMF trauma can result in hemorrhage and airway com­
in potentially longer times until definitive treatment may be promise. These can be immediately life threatening and must
reached. A significant portion of Servicemembers incur injury be addressed expeditiously. Poor outcomes in airway man­
4,5
to the CMF region (42%). Severe CMF trauma can result in agement have been reported that likely are due to the chal­
substantial hemorrhage and airway compromise. These can lenging management of airways in these patients with critical
be immediately life threatening and must be addressed expe­ wounds. Numerous devices and techniques for airway man­
ditiously. Numerous devices and techniques for airway man­ agement have been made available to the forward provider. 4,6,7
agement have been made available to the forward provider. A
thorough review of nonsurgical and surgical airway manage­ A thorough review of nonsurgical and surgical airway man­
ment of the patient with facial injury for the forward provider agement of the patient with facial injury is presented in this
and providers at receiving facilities is provided in this article. article for the forward provider and providers at receiving
Techniques to address flail segments of the facial skeleton are facilities. Techniques to address flail segments of the facial
critical in minimizing airway compromise in these patients. skeleton are critical in minimizing airway compromise in these
There are many methods to control hemorrhage from the head patients. There are many methods to control hemorrhage from
and neck region. Hemorrhage control is critical to ensure sur­ the CMF region, which is essential to ensure survival in the
vival in the austere environment and allow for transport to a austere environment and allow for transport to a definitive
definitive care facility. Associated injuries to the cervical spine, care facility. Associated injuries to the cervical spine, globe,
globe, skull base, carotid artery, and brain must be carefully and skull base must be carefully evaluated and addressed in
evaluated and addressed in these patients. Management of vi­ these patients.
sion­threatening orbital compartment syndrome is critical in
patients with CMF injuries. Because the head and neck region Because the head and neck region remains relatively vulnera­
remains relatively vulnerable in the warfighter, combat CMF ble in the warfighter, combat sustained CMF trauma will con­
trauma will continue to occur. Forward providers will benefit tinue to occur. Forward providers will benefit from a review of
from a review of the acute treatment of CMF traumatic injury. the acute treatment of CMF traumatic injury. Properly triag­
Properly triaging and treating facial injuries is necessary to af­ ing and treating facial injuries are necessary to afford the best
ford the best chance of survival for patients with a devastating chance of survival for patients with a devastating combat CMF
combat CMF injury. injury. In most cases, fracture stabilization and soft­ tissue re­
pair can be delayed until the patient has been stabilized.
Keywords: craniomaxillofacial trauma; airway management;
acute care; hemorrhage; ocular trauma
Systems Management in Craniomaxillofacial Trauma
Airway Management
Introduction Immediate recognition of airway compromise is critically
important in the patient who sustains a combat CMF injury.
As the United States continues to increase its use of Special Establishment of a stable and functioning airway according
Operations Forces worldwide, treatment of craniomaxillofa­ to advanced trauma life support protocols should be of the
cial (CMF) trauma must be adapted to meet the needs of the utmost importance. Assessment and management of the air­
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warfighter. The remoteness of Special Operations can result in way in a patient with severe CMF trauma can be a challenge.
to potentially longer times until definitive treatment may be Adams et al. reported that 5% of patients arriving at a com­
4
reached. Recent reviews on trauma sustained in US combat bat support hospital did not have a definitive airway placed,
operations revealed a substantial portion of Servicemembers although one was needed. Complications related to airway
*Correspondence to The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Plastic Surgery, 7703
Floyd Curl Dr, MC 7844, San Antonio, TX 78229­3900; or sfarber5@gmail.com
1 LCDR Farber, US Navy Reserve, Medical Corps, was formerly at NYU Langone Health, Hansjorg Wyss Department of Plastic Surgery, New
York, NY. Dr Kantar is at NYU Langone Health, Hansjorg Wyss Department of Plastic Surgery. Dr Rodriguez is at NYU Langone Health,
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Hansjorg Wyss Department of Plastic Surgery.
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