**4. Management of cranial-facial trauma in the context of COVID-19 pandemics**

Trauma is an emergency pathology requiring urgent admission with quick analysis and treatment even in the context of current SARS-COV2 pandemics. Therefore, each hospital must establish a clear circuit of the patient from presentation to emergency distribution, operating room, and designated ICU compartment [53].

Cases with multiple traumas must be considered a highly COVID-19 suspect case, and the medical personnel attending the patient should wear level 3 personal protective equipment (PPE). These cases require testing with both rapid serological tests for SARS-COV2 and nasopharynx swab for RT-PCR testing before any maneuver in the emergency department [54].

In cases requiring CPR, the protocol has changed requiring paramedics to wear at least level 2 PPE and to restrain from performing external cardiac compressions and mouth-to-mouth breathing. These maneuvers should be performed by designated personnel equipped according to the national guidelines. The ENT and OMF surgeon is solicited in emergency cases with nasal bleeding, cases with difficult intubation due to neck-associated trauma, or mandible complex fractures. Regardless of the type of emergency, the ENT or OMF surgeon must be equipped with high-level PPE due to the high risk of contamination with SARS-COV2 attending trauma patients [55].

**95**

*Diagnosis and Treatment of Midface Trauma in the Context of Polytrauma: Characteristics…*

After examining the fractures, the patient is often transferred directly into the operating room allotted to COVID-19 cases due to its still uncertain virologic status. A major problem is that the results from the RT-PCR test are available only after some hours in the best-case scenario if not even the next day in some medical facilities. The operating room assigned for COVID-19 suspects must be isolated from operating rooms used in other elective surgeries. Following the example of Singapore, this operating room should be remotely placed and equipped with negative air pressure if possible. Moreover, it should be equipped with designated mobile imaging equipment. The access circuit in this operating theater should be specially designed and prevent cross-contamination of patients and personnel. The surgery should be performed with level 3 PPE equipment for

From the operating room, the patient is taken to the ICU specially designed for

If the result of the test is negative, the patient will be transferred to the ICU designated for non-COVID cases and undergo the management of a usual multiple trauma victim. Craniofacial fractures need reassessment after 48 hours according to the previously stated guidelines. If the result of the RT-PCR is positive, the case needs to be stabilized and transferred to a designated COVID-19 support hospital. In this case, an examination of an infectious disease specialist is also necessary. The current COVID-19 pandemics changes the type of emergency healthcare provided considering any trauma case as positive from the very beginning and requiring all personnel to wear level 3 PPE along with allotting separate diagnosis and treatment circuits with a reduced number of doctors but highly trained and referral as quickly as possible toward the COVID-19 designated healthcare facility

In complex cases with severe deformity, avoid a conservative approach via small multiple regional "conservative" incisions. For a successful outcome, it is best to achieve a complete regional exposure through a coronal or hemicoronal flap combined with lower eyelid or intraoral incision if necessary. Do not delay the surgical intervention for more than 14 days. Except in a few numbers of severe polytrauma cases, the general condition of the patient should be stabilized in this time frame, and definitive treatment should be undertaken. After 14 days the case has to follow the protocol of secondary reconstruction, because of the consolidation of the fractures and the treatment is incomparably more difficult. Do not evaluate the CT scan only in the axial view. For a complete assessment, it is mandatory to examine the CT scan in coronal, frontal, and 3D reconstruction views. If the clinical signs are not convergent with the CT scan interpretation, or if the fractures visible on the CT scan are associated with very little or no functional deficit, the "wait-and-see" or "conservative" approach should be taken into consideration, with the focus on glucocorticoid treatment. Surgical techniques should be tailored taking into consideration the functional and esthetic deficits and using a complex team of trained specialists. The principles of osteosynthesis in midface trauma respect the general principles of osteosynthesis. The prognosis depends on the associated pathology, age, social status, and correct assessment of viscerocranium lesions able to provide surgical and postop care. The current COVID-19 pandemic modifies the level of emergency care toward conservative attitude for trauma cases. Consider every trauma case as a possible COVID-19 suspect, and train the staff to equip quickly level 3 PPE. Keys to success are

the COVID-19 suspect cases until obtaining the results of the RT-PCR test.

*DOI: http://dx.doi.org/10.5772/intechopen.92862*

the entire staff.

for further management.

**5. Conclusions**

*Diagnosis and Treatment of Midface Trauma in the Context of Polytrauma: Characteristics… DOI: http://dx.doi.org/10.5772/intechopen.92862*

After examining the fractures, the patient is often transferred directly into the operating room allotted to COVID-19 cases due to its still uncertain virologic status. A major problem is that the results from the RT-PCR test are available only after some hours in the best-case scenario if not even the next day in some medical facilities. The operating room assigned for COVID-19 suspects must be isolated from operating rooms used in other elective surgeries. Following the example of Singapore, this operating room should be remotely placed and equipped with negative air pressure if possible. Moreover, it should be equipped with designated mobile imaging equipment. The access circuit in this operating theater should be specially designed and prevent cross-contamination of patients and personnel. The surgery should be performed with level 3 PPE equipment for the entire staff.

From the operating room, the patient is taken to the ICU specially designed for the COVID-19 suspect cases until obtaining the results of the RT-PCR test.

If the result of the test is negative, the patient will be transferred to the ICU designated for non-COVID cases and undergo the management of a usual multiple trauma victim. Craniofacial fractures need reassessment after 48 hours according to the previously stated guidelines. If the result of the RT-PCR is positive, the case needs to be stabilized and transferred to a designated COVID-19 support hospital. In this case, an examination of an infectious disease specialist is also necessary.

The current COVID-19 pandemics changes the type of emergency healthcare provided considering any trauma case as positive from the very beginning and requiring all personnel to wear level 3 PPE along with allotting separate diagnosis and treatment circuits with a reduced number of doctors but highly trained and referral as quickly as possible toward the COVID-19 designated healthcare facility for further management.

## **5. Conclusions**

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

even psychiatric support in self-inflicted lesions [49].

**3.9 Indication of surgical treatment in craniofacial trauma**

to enable remission of edema and patient stabilization [50].

along with solving other fractures within 4–5 days from trauma [51].

paranasal sinuses of blood clots [45].

secretions [46].

swelling [48].

outcome [52].

**pandemics**

ver in the emergency department [54].

ing trauma patients [55].

Other treatments in managing midfacial trauma include the following:

• **Early removal of nasal packing in the first 24 hours** enables clearing the

• **Nasal sprays** enable correct daily cleaning of the nasal cavity and drainage of

• **Vitamins B** are useful for preserving neural functions affected by trauma [47].

• **Psychological support** is compulsory in head and neck trauma cases, and the attending surgeon and specialized clinical psychologist should be involved or

Surgical treatment should focus on functional and esthetic deficits. Regarding early intervention in facial trauma, neurosurgeons consider the risks greater than the benefits. Therefore, surgery in these cases should be scheduled within 4–7 days

An exception from this rule is nasal bone fractures which require reduction within the first 24–48 hours from the accident to prevent secondary skull base fractures. We emphasized previously that this is possible under general anesthesia

Given the presence of CSF leak, the surgery must be postponed, and surgical reduction of fractures is possible within 10 days without a major change of the

**4. Management of cranial-facial trauma in the context of COVID-19** 

Trauma is an emergency pathology requiring urgent admission with quick analysis and treatment even in the context of current SARS-COV2 pandemics. Therefore, each hospital must establish a clear circuit of the patient from presentation to emergency distribution, operating room, and designated ICU compartment [53]. Cases with multiple traumas must be considered a highly COVID-19 suspect case, and the medical personnel attending the patient should wear level 3 personal protective equipment (PPE). These cases require testing with both rapid serological tests for SARS-COV2 and nasopharynx swab for RT-PCR testing before any maneu-

In cases requiring CPR, the protocol has changed requiring paramedics to wear

at least level 2 PPE and to restrain from performing external cardiac compressions and mouth-to-mouth breathing. These maneuvers should be performed by designated personnel equipped according to the national guidelines. The ENT and OMF surgeon is solicited in emergency cases with nasal bleeding, cases with difficult intubation due to neck-associated trauma, or mandible complex fractures. Regardless of the type of emergency, the ENT or OMF surgeon must be equipped with high-level PPE due to the high risk of contamination with SARS-COV2 attend-

• **Injectable vitamin C** in high quantity quickens the resolution of facial

**94**

In complex cases with severe deformity, avoid a conservative approach via small multiple regional "conservative" incisions. For a successful outcome, it is best to achieve a complete regional exposure through a coronal or hemicoronal flap combined with lower eyelid or intraoral incision if necessary. Do not delay the surgical intervention for more than 14 days. Except in a few numbers of severe polytrauma cases, the general condition of the patient should be stabilized in this time frame, and definitive treatment should be undertaken. After 14 days the case has to follow the protocol of secondary reconstruction, because of the consolidation of the fractures and the treatment is incomparably more difficult. Do not evaluate the CT scan only in the axial view. For a complete assessment, it is mandatory to examine the CT scan in coronal, frontal, and 3D reconstruction views. If the clinical signs are not convergent with the CT scan interpretation, or if the fractures visible on the CT scan are associated with very little or no functional deficit, the "wait-and-see" or "conservative" approach should be taken into consideration, with the focus on glucocorticoid treatment. Surgical techniques should be tailored taking into consideration the functional and esthetic deficits and using a complex team of trained specialists. The principles of osteosynthesis in midface trauma respect the general principles of osteosynthesis. The prognosis depends on the associated pathology, age, social status, and correct assessment of viscerocranium lesions able to provide surgical and postop care. The current COVID-19 pandemic modifies the level of emergency care toward conservative attitude for trauma cases. Consider every trauma case as a possible COVID-19 suspect, and train the staff to equip quickly level 3 PPE. Keys to success are

designing special access circuits for trauma cases reducing the time spent in the ER and subsequent referral of the case to specialized medical facilities treating COVID-19 cases.
