A Guide to Facial Trauma Triage and Precautions in the COVID-19 Pandemic

Abstract

COVID-19 is an emerging viral illness that has rapidly transmitted throughout the world. Its impact on society and the health care system has compelled hospitals to quickly adapt and innovate as new information about the disease is uncovered. During this pandemic, essential medical and surgical services must be carried out while minimizing the risk of disease transmission to health care workers. There is an elevated risk of COVID-19 viral transmission to health care workers during surgical procedures of the head and neck due to potential aerosolization of viral particles from the oral cavity/naso-oropharynx mucosa. Thus, patients with facial fractures pose unique challenges to the variety of injuries and special considerations, including triaging injuries and protective measures against infection. The proximity to the oral cavity/naso-oropharyngeal mucosa, and potential for aerosolization of secretions containing viral particles during surgical procedures make most patients undergoing operative interventions for facial fractures high risk for COVID-19 transmission. Our proposed algorithm aims to balance patient care with patient/medical personnel protection as well as judicious health care utilization. It stratifies facial trauma procedures by urgency and assigns a recommended level of personal protective equipment, extreme or enhanced, incorporating current best practices and existing data on viral transmission. As this pandemic continues to evolve and more information is obtained, the protocol can be further refined and individualized to each institution.

Head and Neck Practice in the COVID-19 Pandemics Today: A Rapid Systematic Review

“…11 Other studies extended the roll of procedures to treat to conditions in which the delay of intervention could worsen functional and aesthetic outcomes. 26,30 Other procedures should be postponed for 30 days or more, with frequent revaluations. Only two reports distinguish about this guidance.…”

“…Some articles showed superiority of PAPR over other masks. 26,30,35 It was demonstrated that PAPR has a higher assigned protective factor than N95 (25-100 versus 10). 25 However, due to management of resources and disponibility of these devices, two articles presented a stratification of risk status; thus, they reserve the use of PAPR only in situations of higher risk of aerosolization and viral exposure.…”

“…The suggested workflow indicates two categories: 1) extreme airborne protection that demands the use of PAPR and is reserved to high aerosolization procedures (e.g., tracheostomy, endoscopy and the access of aerodigestive mucous), and 2) enhanced airborne protection, which allows the use of N95 masks and is indicated for cases of mild-risk of contamination. 26,30 Nevertheless, PAPR can be incompatible with some procedures, because it does not allow the use of instruments by the surgeon, for instance, loupes, headlight, and microscope. 20,35 It is also necessary to emphasize the importance of correct use and disposal of PPE, as some literature brings to evidence that failure in these steps can be related to high infection rates in health care workers.…”

“…The use of powered devices, like drills, microdebriders, saws, or ultrasonic shears, ought to avoided, and if they are used, irrigation pressure must be kept to a minimum. 26…”

Plastic Surgeons and COVID-19 Pandemic

“…It is also vital to reduce the aerosol-generating procedures, for example, intubation, tracheostomy, maxillofacial and other intraoral surgeries; use of rotatory power tools during K-wire and plate fixations have also been documented as aerosol-generating. 14,15 Now, we are aware that SARS-CoV-2 virus stays in the environment for as long as 9 days, so these procedures need extra precautions. 16 Along with the complete PPE.…”