POTD: Le Fort Fractures

Hello everyone!

For trauma Tuesday, let's discuss Le Fort fractures.

Le Fort fractures are complex facial fractures involving the maxilla, zygoma, and orbital rims. They were discovered by Dr. Rene Le Fort who discovered these "lines of weakness" in skulls of patients with blunt facial traumas. These fractures by nature include the pterygoid structures of the sphenoid bone, which provide stability and support for the mid face. Most commonly seen in MVC, the velocity determines the severity of the fractures, of which there are three categories:

Le Fort I: "floating palate"

- a transverse fracture of the maxillae above the teeth, leaving the body of the maxilla separated from the pterygoid plate and nasal septum. This leads to a "floating palate", where the maxilla and hard palate may be mobile.

- associated with malocclusion and dental fractures

- generally considered a stable fracture

Le Fort II: "floating maxilla"

- fracture that extends superiorly to include the nasal bridge, maxilla, and orbital rim and floors. fractures are typically bilateral and appear triangular in shape

- The maxilla and nose are mobile, the eyes/orbits are not

- can be stable or unstable

Le Fort III: "floating face"

- the rarest and most severe, this fracture involves the bridge of the nose, medial and lateral orbital wall, zygomatic arch, and maxilla. 

- the entire face is mobile, can present as a "dish face" deformity (essentially the face is caved in)

- this is an unstable fracture

Presentation and Evaluation:

Le Fort fractures can present with many features, including facial deformity and emphysema, CSF rhinorrhea, conjunctival hemorrhage, raccoon eyes, hemotympanum and auricular hematoma, and anosmia

Questions to ask:

Can you smell? Can you bite? 

How is your vision?

Is there numbness or tingling in you face?

Exam:

- palpate for signs of crepitus, areas of tenderness, or instability

- visual acuity test - very important considering high risk of ophthalmologic damage

- check mobility by stabilizing the forehead and grabbing the upper teeth/hard palate, and attempt to move the hard palate

-evaluate to c-spine injuries - approximately 1.4% have concomitant c-spine injuries or dislocations

Management:

- Stabilize ABCs. If airway is at risk - understand that it will be a difficult airway, and consider awake intubation. These patients are particularly difficult as oral injury may prevent appropriate jaw displacement for oral intubation. Nasal intubations are contraindicated due to nasal injuries. These are patients where if a definitive airway is needed, cricothyroidotomy should be considered.

- significant nasal bleeding can occur and may present an airway risk. Consider anterior packing and elevation of head of bed to 40-60 degrees. Posterior packing should be avoided due to risk of skull base injuries.

- IV antibiotics should be given in sinus fractures or CSF leaks, which will be the majority of these fractures

- CT with dedicated facial view should be obtained. 

Disposition:

- All Le Fort fractures should be seen by OMFS

- consider Ophtho or NSG consult if there is concern for eye or brain damage/CSF leak

- some stable Le Fort I and II are stable for discharge with follow up, however most will require ICU (for airway management) or direct OR 

http://www.emdocs.net/em3am-le-fort-fractures/

https://www.ncbi.nlm.nih.gov/books/NBK526060/

https://coreem.net/core/le-fort-fractures/

EMS Protocol of the Week: Pediatric Respiratory Distress/Failure

Hey all,

This week's EMS protocol is on pediatric respiratory distress/failure. The thought of a pediatric patient experiencing respiratory distress is enough to cause me to go into respiratory distress... but let's discuss how our pre-hospital colleagues initiate care for these patients.

Remember that respiratory distress and respiratory failure fall on a spectrum:

Respiratory distress is characterized by:

- Increased respiratory effort/WOB

- ABSENCE of central cyanosis symptoms: anxiety, nasal flaring, increased respiratory rate, accessory muscle use (ie retractions), lethargy, etc.)

Respiratory failure is characterized by:

- Presence of central cyanosis symptoms: agitation, lethargy, severe dyspnea, labored breathing, head bobbing, grunting, severe retractions, severe bradypnea, etc.

- Hypoxia and/or hypercapnia

The prehospital approach to these kiddos corresponds to a progression of care based on the level of training present. CFRs start with ABCs and monitoring vital signs. If needed, these providers can implement airway adjuncts and administer supplemental O2 at appropriate levels for either respiratory distress or failure. At this level of training, CFRs can then address potential overdose. BLS crews will pick up from here and can additionally request ALS backup and transport the patient. If the on-scene team is ALS trained, they can perform advanced airway management if unable to continually bag ventilate the patient. From here, ALS providers will start cardiac monitoring and establish IV/IO access as necessary while en route. They can even assess and treat for a tension pneumothorax (which may develop after resuscitation has begun!).

If a known cause is identified/suspected such as aspirated foreign body or anaphylaxis, treatment via those protocols will be used. If persistence of respiratory distress/failure, then providers will default back to this protocol.

There is not a lot to be aware of from an OLMC (shameless plug for our e-mailed survey 😊) standpoint other than awareness of the level of care the on-scene providers are able to provide - this will give the receiving team a better idea of what to expect when the patient is rolled in and instill the appropriate level of fear.

See the attached protocol and check out https://nycremsco.org/ for more!

Best,
Zachary Kim

PGY-2 Emergency Medicine

Decision Making Capacity

In the 1914 case of Schloendorff versus the Society of New York Hospital, Justice Cardozo wrote, “every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Determining a "sound mind," or decision making capacity is something that we do often in the emergency department. This makes many providers uncomfortable because it gives patients the ability to refuse our recommendations. This POTD is going to go over what defines capacity and how we can assess it. 

Capacity refers to the ability of a person to utilize information about their illness and proposed treatments to make a choice that aligns with their values. Determining capacity is often a clinical judgment typically made by a physician, whereas competence is a legal state determined by a judge. Assessing for capacity allows us to act in our patient’s best interest while respecting their autonomy. 

You can assess for capacity by determining if the patient has the ability to: 1. Communicate 2. Understand the information 3. Understand the situation 4. Manipulate the information presented and make a logical decision.

These points can be ascertained by asking the patient to recount their story, your recommendations, state what they do or don't want, and back their decision up with logic. 

It is important to note that capacity is defined around a specific medical decision; you should assess capacity with each new intervention or treatment proposed. In addition, capacity can be transient and exist along a continuum. So before you call up psych to help determine if your patient can refuse dialysis, go through these 4 points and see if you can determine decision making capacity yourself.

Thanks for reading!

Ariella

References: 

https://www.emrap.org/episode/november2014/decisionmaking

https://www.uptodate.com/contents/assessment-of-decision-making-capacity-in-adults

Ariella Cohen

M.D. Emergency Medicine

Maimonides Medical Center