11.4 Maxillofacial, Ocular, and Neck Trauma
Key Takeaways
- Le Fort and bilateral mandible injuries are airway and hemorrhage problems; stage two suctions and expect a soiled or surgical airway.
- Assume a cribriform-plate fracture with midface trauma or CSF rhinorrhea—orogastric tube only, never nasogastric or casual nasal intubation.
- Shield a ruptured globe without pressure, irrigate chemical burns, sit hyphema up, and treat retrobulbar hematoma as a physician- or protocol-only canthotomy emergency.
- Hard signs of neck injury—airway compromise, expanding or pulsatile hematoma, pulsatile bleed, neurologic deficit, bubbling—go to the operating room; do not probe or pull impaled objects.
- A rigid C-collar can hide an expanding hematoma; reopen it on a schedule after packaging, lift, and every cabin-altitude change.
Face and neck trauma kill by airway and by hidden hemorrhage, not by a crooked nose. Domain 3.C of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests maxillofacial, ocular, and neck trauma because midface bleeding, a ruptured globe, and a penetrating neck wound all get worse in a tight cabin you cannot easily re-examine.
Midface, Le Fort, and mandible
Le Fort fractures are midface patterns. Le Fort I is a floating palate through the maxilla. Le Fort II is pyramidal through the nasal bridge and orbits. Le Fort III is craniofacial dysjunction. All three can produce massive epistaxis, a soiled airway, and an uncleared cervical (C-)spine. Sit the patient forward if they are awake and the spine package allows. Prepare two suctions. A midface that telescopes under bag-mask pressure is a predicted failed mask—stage a supraglottic backup and an open surgical kit.
A mandible fracture, especially bilateral, lets the tongue fall back. Feel for a step-off and floor-of-mouth swelling. A rapidly expanding sublingual hematoma is an airway now, not a dental consult. Swallowed blood also sets up vomiting on climb.
Cribriform plates and tubes
Assume a cribriform plate fracture with midface trauma, raccoon eyes, Battle sign, or cerebrospinal fluid (CSF) rhinorrhea. Do not place a nasogastric (NG) tube—it can enter the cranial vault. Use an orogastric (OG) tube only. The same rule applies to nasotracheal tubes and nasal trumpets; go oral or surgical. Documented pneumocephalus can expand under Boyle's law on climb; request a lower cabin.
| Injury | Flight threat | Immediate move |
|---|---|---|
| Le Fort I–III | Epistaxis, unstable midface, soiled airway | Two suctions; early definitive or surgical airway |
| Bilateral mandible | Tongue fallback, floor-of-mouth hematoma | Sit up if able; prepare to intubate or cut |
| Cribriform / basilar skull | Intracranial NG, CSF leak, pneumocephalus | OG only; no nasal tubes; consider a lower cabin |
| Isolated nasal fracture | Usually not the killer | Still reassess for septal hematoma and associated C-spine |
Ocular injuries
A ruptured globe is a soft, irregular, or peaked pupil with extruded contents or a shallow anterior chamber after penetrating or high-velocity blunt trauma. Place a rigid eye shield. Do not patch with gauze that presses. Do not check intraocular pressure. Do not put a dressing that turns the orbit into a tamponade. Antiemetics matter; vomiting raises venous and intraocular pressure in a cabin that already makes people sick.
Chemical burns are an irrigate-now injury. Start water or saline on the scene and continue into the aircraft. Alkali is worse than acid. Do not try to neutralize with the opposite chemical. Flip the lids if you can and keep flushing until the receiving team takes over.
Hyphema is blood in the anterior chamber. Sit the patient up to layer the blood. Reassess vision and pain after climb. Coughing and a hypoxic agitated climb raise venous pressure into that chamber.
Retrobulbar hematoma is orbital compartment syndrome: proptosis, rock-hard lids, an afferent pupillary defect, and falling vision. The rescue is lateral canthotomy and cantholysis—a physician or tightly protocolled procedure, not a skill you invent at 3,000 feet. Recognize it, raise the surgeon while you are still on the ground if you can, keep the head up, and do not press on the globe.
Neck: blunt, penetrating, zones, and the collar
Hard signs of a significant neck injury go to the operating room, not to a long scene ultrasound:
- Airway compromise or massive subcutaneous emphysema
- Expanding or pulsatile hematoma
- Active pulsatile bleeding
- Unexplained neurologic deficit (stroke-like findings, or an evolving cord)
- Bubbling from the wound, or hemoptysis that means an airway leak
Do not probe the wound. Do not remove an impaled object. Do not take a "quick look" under a clot. Direct pressure around, not into, a penetrating track. A commercial hemostatic dressing and a careful seal beat curiosity.
Zone anatomy at a high level: Zone I is clavicles to cricoid (great vessels, lung apices, trachea—injuries hide in the chest). Zone II is cricoid to the angle of the mandible (carotids, jugulars, trachea, esophagus—most common). Zone III is angle of mandible to skull base (distal carotids, cranial nerves—hard to expose). Modern practice is hard signs versus no hard signs more than mandatory Zone II exploration.
Blunt neck trauma adds laryngotracheal disruption (voice change, stridor, subcutaneous air) and vascular intimal injury (a delayed stroke). A seat-belt mark across the neck is a vascular study at the trauma center, not a cleared collar on the ramp.
A rigid C-collar can hide an expanding hematoma. Open it after packaging, after lift, and after every cabin-altitude change. An occult Zone II hematoma is an airway you will not get back once the collar is blood-soaked. If the airway is closing, manage it on the ground. Hard signs go to an operating room with trauma and airway backup, not a closer hospital that will only scan the neck.
- Midface and bilateral mandible injuries are airway problems first.
- Cribriform injury means OG only—never NG.
- Shield a ruptured globe; irrigate chemicals; sit hyphema up; treat retrobulbar hematoma as a canthotomy emergency for a physician or protocol.
- Hard signs go to the operating room; do not probe; do not pull the knife.
- Reassess under the collar.
A helmeted motorcyclist has midface instability and clear fluid from the nose. The sending nurse hands you a nasogastric tube "to decompress before flight." What is the correct tube choice?
A penetrating Zone II neck wound is bubbling, and a pulsatile hematoma is expanding under the dressing. The object is still in place. What is the correct next action?
After packaging a blunt seat-belt neck injury, the rigid collar is tight and you cannot see the anterior neck. What is the best reassessment plan for flight?