Who to suspect?

High-energy facial impact (RTC/motorbike, assault, fall, industrial)
Midface deformity or malar flattening
Malocclusion or trismus
Diplopia or infraorbital hypoesthesia
Epistaxis (esp. posterior)
Clear rhinorrhea/otorrhea (CSF leak)
Periorbital swelling or “white-eye” pediatric blowout

Red flags (time-critical):

Threatened airway/aspiration (blood, avulsed teeth)
Torrential midface bleeding
Vision change or proptosis (orbital compartment syndrome; OCS)
Afferent pupillary defect
Oculocardiac reflex in children (bradycardia with upgaze → entrapment)
Septal hematoma
Open globe signs
Clear CSF leak
Expanding neck hematoma.

1) Rapid Clinical Assessment & Stabilization

Airway/bleeding:
- Sit up, suction, two-person BVM if needed
- Jaw thrust
- Avoid NPAs when basilar skull fracture suspected
- Early RSI with full backup
- Control facial hemorrhage with direct pressure
  - Anterior/posterior balloon packs
  - IR/ECA embolization if refractory
Orbital Compartment Syndrome (OCS) rule-out:
→ immediate canthotomy/cantholysis; don’t delay for imaging.
- Painful proptosis
- Decreased vision
- RAPD
- Ophthalmoplegia
- IOP↑
CSF leak: head up, avoid nose-blowing/NGT through nose. Routine prophylactic antibiotics not recommended.

2) Imaging & Tests

CT: Maxillofacial thin-slice ± head
- 3-D recon for surgical planning, but 2-D shows fracture lines best.
- C-spine per trauma risk.
Labs: FBC, VBG/ABG, glucose, coagulation panel, type & screen.
Ocular US: for retinal detachment/vitreous hemorrhage only if no open-globe suspicion. (If open globe suspected: shield, no pressure.)

Le Fort Fracture

Orbital blowout fracture

3) Condition-Directed Management

A. Airway & hemorrhage control

Prioritize airway over anatomy; secure it early if in doubt. Avoid nasotracheal in potential basilar skull fracture. Pack anterior/posterior epistaxis; escalate to IR if persistent.
Topical TXA for anterior epistaxis is reasonable to reduce re-bleeding.

B. Orbital injuries

OCS: emergent lateral canthotomy/cantholysis.
Blowout with entrapment / OCR (esp. pediatrics): urgent Ophth/OMFS; early repair typically within ≤2 weeks (sooner if true entrapment/white-eye).

C. Septal hematoma / nasal fracture

Drain septal hematoma immediately to prevent necrosis/saddle nose; pack and refer.
Isolated closed nasal fracture without hematoma can be outpatient with ENT/OMFS review (5–10 days).

D. Midface (Le Fort / ZMC / NOE)

Recognize pterygoid plate involvement for Le Fort; look for malar flattening/step deformity in ZMC.
Early specialist input; most are semi-urgent rather than emergent unless airway/bleeding/vision risk.

E. Mandible

Clinical screen with tongue-blade test (high sensitivity/NPV); confirm with CT. Manage pain, soft diet, Barton bandage if needed; prompt OMFS follow-up.

F. Antibiotics

Open fractures (communicating with oral cavity/sinuses) and through-and-through lacerations:
- Short-course prophylaxis appropriate.
Closed, non-contaminated facial fractures:
- Routine prophylaxis not recommended.
Basilar skull fracture/CSF leak:
- Routine prophylaxis not supported by evidence.

G. CSF leak

Confirm with β-2 transferrin
Neurosurgery/ENT for localization and repair.
Avoid nasal instrumentation.

4) Disposition & Observation

ED discharge (selective)
Short-stay observation (12–24 h)
- Soft-tissue swelling obscuring ocular exam
- Equivocal diplopia improving with decongestion
- Minor ZMC without trismus/IO nerve deficit
Admit / OR
- OCS needing decompression
- Open fractures
- Le Fort with airway/bleed risks
- CSF leak
- NOE with telecanthus
- Unstable occlusion
- Polytrauma.

References

American College of Surgeons. (2025, March 26). ATLS 11th edition: Learning labs & updates. https://www.facs.org/quality-programs/trauma/education/advanced-trauma-life-support/atls-11/ ACS+1
Appelbaum, R. D., Martin, N. D., McCarthy, C. M., Bokhari, F., Brown, C. V. R., Gunter, O. L., … AAST Critical Care Committee. (2024). Antibiotic prophylaxis in injury: An American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surgery & Acute Care Open, 9(1), e001304. https://doi.org/10.1136/tsaco-2023-001304 BMJ Tsaco
Barak, M., Bahouth, H., Leiser, Y., Abu El-Naaj, I., & Laufer, D. (2015). Airway management of the patient with maxillofacial trauma. Anesthesiology Research and Practice, 2015, 724032. https://doi.org/10.1155/2015/724032 PMC
Bera, R. N., Debnath, R., & Sen, C. (2021). Does early treatment of paediatric orbital fracture offer better outcomes? Cureus, 13(3), e14016. https://doi.org/10.7759/cureus.14016 PMC
Gómez Roselló, E., García-Espona, M. A., & Martí-Aguado, D. (2020). Facial fractures: Classification and highlights for a useful report. Insights into Imaging, 11, 121. https://doi.org/10.1186/s13244-020-00847-w SpringerOpen
Joseph, J., Martinez-Devesa, P., Belloso, A., & Burton, M. J. (2018). Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database of Systematic Reviews, 2018(12), CD004328. https://doi.org/10.1002/14651858.CD004328.pub3 PubMed
Kumar, S., Jamal, B. T., & Krishnan, V. (2022). Retrobulbar hematoma. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK576417/ NCBI
National Institute for Health and Care Excellence. (2025, June 23 review). Fractures (non-complex): Assessment and management (NG38). https://www.nice.org.uk/guidance/ng38 NICE
Patel, B. C., & Coon, D. (2023). Le Fort fractures. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526060/ NCBI
Rhea, J. T., Rao, P. M., & Novelline, R. A. (2005). How to simplify the CT diagnosis of Le Fort fractures. American Journal of Roentgenology, 184(5), 1700–1705. https://doi.org/10.2214/AJR.184.5.01841700 AJR Online
Ratilal, B. O., Costa, J., Pappamikail, L., & Sampaio, C. (2015). Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database of Systematic Reviews, 2015(4), CD004884. https://doi.org/10.1002/14651858.CD004884.pub4 PMC
Reuben, A., Varadarajan, V. V., Al-Khabori, M., et al. (2021). The use of tranexamic acid to reduce the need for nasal packing in epistaxis (NoPAC): A randomized controlled trial. Annals of Emergency Medicine, 78(5), 622–631. https://doi.org/10.1016/j.annemergmed.2020.12.021 ScienceDirect
Zahed, R., Moharamzadeh, P., Alizadeh Ardalan, F., Ghasemi, A., Saeedi, M., & Safari, S. (2018). Topical tranexamic acid compared with anterior nasal packing for epistaxis. Academic Emergency Medicine, 25(3), 261–266. https://doi.org/10.1111/acem.13346 PubMed
AO Foundation. (2025). AO Surgery Reference—CMF trauma: Emergency treatment. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/emergency-treatment