Ep 220 Facial Injuries: Assessment, Management and Disposition

June 30, 2026

AI Summary

5 min read

A 34-year-old man is punched repeatedly outside a bar. He is alert, speaking in full sentences, but has significant midface swelling, epistaxis that requires pressure, periorbital ecchymosis, a bite that feels off, and double vision. On exam, he has tenderness over the nasal bridge and infraorbital rims, obvious malocclusion, limited upward gaze on the right, and mild trismus. His GCS is 15. This case, presented at the top of the episode, anchors a practical, top-down approach to facial injuries in the emergency department. The core message: CT will find the fractures, but the emergency physician's job is to identify which injuries threaten vision, airway, or long-term function—and which can safely wait.

The Airway and Bleeding: Anticipate, Don't Just React

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What you'll learn

1 (00:03) **Episode Introduction & Case Presentation** - Hosts Anton and Katie introduce the topic of facial injuries and present a case of a 34-year-old man assaulted with midface swelling, epistaxis, malocclusion, and diplopia.
2 (04:48) **Immediate Assessment & Airway Priorities** - The experts discuss the first steps at the bedside for a stable patient with facial injuries.
3 (07:26) **Airway & Bleeding Management** - Detailed discussion on anticipating airway deterioration and managing hemorrhage in facial trauma.
4 (19:38) **Associated Injuries & Imaging Decisions** - Discussion on missed injuries and when to order facial CT.
5 (33:39) **Top-to-Bottom Fracture Approach: Upper Face (Frontal Bone)** - Red flags and management of frontal sinus fractures.
6 (38:03) **Orbital Blowout Fractures** - Assessment, red flags, and surgical urgency.
7 (48:57) **Midface Fractures: Nasal & NOE** - Assessment of nasal fractures and naso-orbital-ethmoid (NOE) complex.

+ Full timestamped outline available in the app

Show Notes

Facial trauma is common in emergency medicine, but the biggest pitfalls are often not the fractures themselves—they're the threatened airway, vision-threatening ocular injuries, missed septal hematomas, and subtle soft tissue injuries hiding beneath the skin. Which facial fracture is most likely to cause delayed airway obstruction? Why does the physical examination often matter more than the CT scan? Which injuries require urgent consultation or transfer, and which can safely go home? In this episode of EM Cases, Anton is joined by Dr. Jeff Fialkov and Dr. Andrew Petrosoniak for a practical, top-down approach to facial trauma covering airway, bleeding, vision-threatening injuries, fracture assessment, soft tissue injuries, and disposition. Please consider a donation to EM Cases to ensure ongoing high quality Free Open Access Medical Education here: https://emergencymedicinecases.com/donation/