Step 1 of 6
EV · HIGHPrimary Survey (ABCDE)
ATLS — airway / breathing / circulation / disability / exposure
Every maxillofacial trauma patient is approached as a major-trauma patient first and a facial-injury patient second. The Advanced Trauma Life Support sequence runs in parallel with cervical-spine immobilisation — the cervical-spine injury rate in high-energy facial trauma is meaningful and missed injuries are catastrophic.
Airway with C-spine control is the dominant decision. Mid-face and laryngotracheal injuries can occlude the airway abruptly as oedema develops — early definitive airway control (intubation under inline traction, cricothyroidotomy, or tracheostomy) often pre-empts a much harder rescue. Recognise laryngeal injury: dysphonia, surgical emphysema, haemoptysis, stridor — flexible endolaryngeal evaluation before instrumentation.
- Airway with cervical-spine control
- Breathing — saturation, chest trauma
- Circulation — pulse, BP, IV access, haemorrhage control
- Disability — GCS, pupils, focal deficits
- Exposure — full trauma survey, prevent hypothermia
- Laryngeal red flags — dysphonia · crepitus · haemoptysis · stridor
★ High-yield pearls (chapter-wide)
- ATLS first, face second — airway with C-spine control, then haemorrhage.
- Retrobulbar haematoma is a bedside-canthotomy emergency — do not wait for CT.
- Paediatric white-eyed trapdoor blowout → operate within 24 hours.
- Septal haematoma must be drained on the day of presentation.
- Most facial fractures repair best 5–10 days after injury — after oedema, before fibrosis.
- Restore occlusion via MMF first, then build the midface buttresses.
- Telecanthus + epicanthal flattening = NOE injury until proven otherwise.
- Posterior-table frontal-sinus fracture is a neurosurgical case — cranialise if comminuted or through-and-through.
- Always reassess the orbital floor after ZMC reduction — 25–40 % have concomitant blowout.
- Paediatric facial trauma: conservative bias, preserve growth centres, lifelong growth surveillance.
- CSF rhinorrhoea after midface trauma → avoid nasal instrumentation, neurosurgery in.
- Late mucocele after missed frontal-sinus injury can present decades later — long surveillance.
Evidence base
5 sources- HIGH
American College of Surgeons Committee on Trauma · 2018Trauma manual / consensus reference (non-peer-reviewed)
Global gold-standard trauma reference — defines the ABCDE primary survey, cervical-spine precautions, trauma-airway algorithm, and initial stabilisation framework that anchors this step. Consensus/manual reference, not peer-reviewed evidence. 10th ed. Chicago (IL): American College of Surgeons; 2018.
- MOD
Mulligan RP & Mahabir RC · Head Face Med · 2010Peer review (prospective observational)PMID 19996802
Moderate-quality prospective evidence quantifying the cervical-spine-injury rate in facial-trauma cohorts — supports routine C-spine immobilisation and dedicated cervical imaging. Vol 6:36.
- MOD
Barak M et al. · Br J Oral Maxillofac Surg · 2015Peer review (retrospective review)PMID 26161411
Operational evidence for early airway control in mid-face and panfacial injury — indications for intubation, cricothyroidotomy, and tracheostomy in this population. Vol 53(9):897-900.
- HIGH
Schaefer SD · Laryngoscope · 2014Peer reviewPMID 23804493
Schaefer's modern synthesis of acute blunt and penetrating laryngeal-trauma management — Schaefer classification, fibreoptic-endolaryngoscopy indications, and surgical-airway thresholds. Vol 124(1):233-244.
- HIGH
Schaefer SD · Arch Otolaryngol Head Neck Surg · 1992Peer reviewPMID 1637537
Schaefer's foundational 27-year series — original Schaefer classification of external laryngeal trauma. Historical anchor for the airway-management algorithm. Vol 118(6):598-604.