key: cord-0838671-2ghlocqw
authors: Ghai, Suhani
title: Facial Trauma Management During the COVID-19 Era: A Primer for Surgeons
date: 2020-07-21
journal: Curr Med Res Pract
DOI: 10.1016/j.cmrp.2020.07.011
sha: 6ecd910dc7ccfb6b1420a58e29f920e4c162422d
doc_id: 838671
cord_uid: 2ghlocqw

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has caused more than 6.1 million confirmed cases of COVID-19 in more than 188 countries, and has caused more than 370,000 deaths globally as of June 1, 2020. In addition, thousands of healthcare workers have also got infected with the virus. COVID-19 patients release large amounts of infectious viral particles in form of droplets from cough, sneeze and respiratory secretions. These droplets are the main modes of transmission of COVID-19. This mode of transmission puts the healthcare professionals at an increased risk of infection, especially from asymptomatic patients. As a result, during the current pandemic, most routine surgeries all around the world have been suspended, and only emergency surgeries are being performed. Facial trauma surgery is one such emergency surgery that cannot be delayed or suspended even in this pandemic. This review focuses on precautions surgeons have to take while managing facial trauma patients in the emergency department and while performing emergency surgeries on these patients during the current COVID-19 pandemic.

The World Health Organization (WHO) has officially declared the current outbreak of Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) as a pandemic 1 . This disease which originated from Wuhan, China in December 2019, as of June 1, 2020, has caused more than 6.1 million confirmed cases of COVID-19 in more than 188 countries, and has caused more than 370,000 deaths globally 2 . In addition, till the middle of April 2020, more than nine thousand healthcare workers in United

States have been infected, accounting for 19% of total number of patients data available with the CDC 3 .

The asymptomatic incubation period for patients with COVId-19 has been reported to be 1-14 days 4 . During the symptomatic phase, the main symptoms are fever, dry cough, fatigue, myalgia and dyspnea, but many patients of COVID-19 remain asymptomatic or have only inconspicuous flu like symptoms 5 . During the early phase of infection, whether asymptomatic or symptomatic, patients of COVID-19 release large amounts of infectious viral particles in form of droplets from cough, sneeze and respiratory secretions. These droplets are the main modes of transmission of COVID-19 6 . This mode of transmission puts the healthcare professionals at an increased risk of infection, especially from asymptomatic patients. As a result, during the current pandemic, most routine surgeries all around the world, have been suspended, and only emergency surgeries are being performed 7 . Facial trauma surgery is one such emergency surgery that cannot be delayed or suspended even in this pandemic.

Although most of the facial trauma occurs due to road traffic accidents and sports injuries, which may have reduced during the current lockdown due to COVID-19 pandemic, however, facial injuries due to falls and assaults due to domestic violence continue to occur with same frequency as before. Surgeons managing facial trauma, such as oral and maxilla-facial surgeons, head and neck surgeons, and plastic surgeons are routinely needed in emergency departments, not only to manage facial trauma cases, but also to triage patients, perform swab testing for COVID-19, and help to intubate difficult facial trauma patients 8 .Almost all surgical procedures performed on facial trauma patients require intimate contact with naso-oro-pharyngeal region which carry high viral load SARS-CoV-2, if the patient is positive for COVID-19 6 . This review will focus on precautions surgeons have to take while managing facial trauma patients in the emergency department and while performing emergency surgeries on these patients during the current COVID-19 pandemic.

Published articles and guidelines were searched from PubMed, Google Scholar, Cochrane database, and peer-reviewed ahead-of-print publications. Multiple search terms were employed (independently and in combination with the Boolean method) as a broad net for capturing relevant publications, including facial trauma, COVID-19, SARS-CoV-2, guidelines, respiratory precautions, personal protective equipment, and aerosolization. Regarding specific equipment, such as PPE, specifications published by the manufacturers were also reviewed.

During the current COVID-19 pandemic, every patient who arrives in the emergency department for any reason should be assumed to be positive for COVID-19, till it is proved otherwise by appropriate history, examination, and tests if required. When a patient of facial trauma arrives in the emergency department, every precaution should be taken to ensure prevention of infection to the surgeon, emergency unit staff and other healthcare providers. The emergency resident and staff should wear proper personal protective equipment (PPE), and keeping in mind the current shortage of PPE kits, every effort should be made to limit or avoid unnecessary visits by other healthcare professionals, whose services are not immediately needed in the emergency department. This can be done by evaluating and managing the trauma patient by the emergency resident himself and proper documentation of the history, examination findings, photos and the radiographs. Discussions with the surgeon can be done over audio or video calls, and digital technology can be used for sharing patient's history and examination notes, photographs, blood reports and radiological images. With the teleguidance of the surgeon, soft tissue and minor facial injuries can be managed by the emergency resident and staff without the physical involvement the surgeon. During the current pandemic, telecounseling and teletriaging of patients is the need of the hour, to prevent unnecessary exposure to scarce healthcare providers, and to avoid unnecessary quarantine of the emergency healthcare providers.

In cases of major facial injuries, when physical examination of the patient of facial trauma by the surgeon becomes imperative, the availability of PPE for the facial trauma surgeon becomes essential. The physical examination by surgeon involves very close contact with patient's head and neck before any surgical procedure can be planned. As naso-oro-pharyngeal region carry a high viral load SARS-CoV-2 extreme precaution is needed 9 .In addition, surgeon needs to be familiar with proper donning and doffing techniques of the PPE kits.

Since there is high risk of infection in management of facial trauma owing to the high viral load in the oral cavity and naso-oro-pharyngeal region, triaging the patients to decide the type of personal protection and treatment plays an important role in the current pandemic.

Generally, the facial trauma patients can be triaged into three groups depending on the nature and extent of injury: Patients requiring urgent surgeries; patients requiring semi-urgent surgeries; and patients requiring delayed surgeries.

When emergency surgery has to be performed in cases of life-threatening traumas, and the COVID-19 status of the patient cannot be immediately tested, extreme airborne precautions are recommended during the emergency surgery. These include powered air purifying respiratory (PAPR), fluid-resistant gown, and surgical gloves 10 .If not available, as in countries with limited resources, enhanced airborne precautions should be taken using N95 mask, face shield/eye protection, fluid-resistant gown, caps and surgical gloves 10, 11 .

There may be facial injuries which are less urgent but nevertheless have to be managed like in cases where delayed management might lead to infection, permanent functional and esthetic deformity. In such cases COVID-19 testing can be performed. The Stanford University protocol recommends 48 hours of pre-operative testing that includes two COVID-19 tests done 24 hours apart. In case both the tests are negative, enhanced airborne precautions can be used. In case either one test is positive, extreme airborne precautions should be undertaken 12 . The detection of nucleic acid of SARS-CoV-2 shows high false negative rate and therefore caution must always be exercised 13 .

In cases where there is no emergency, the patients should be observed, treated in the emergency department as outpatients and/or treated electively. Patients should be thoroughly informed and be counseled regarding the on-going pandemic and risk-benefit ratio of delaying the treatment.

Status:

During surgery only absolutely required number of healthcare providers, including anesthetic team and nursing staff should be allowed inside operating room. All operators should wear the required PPE, double gloves and perform hand hygiene. If PAPR is not available, a FFP3 mask with visors or goggles should be worn especially while operating on infected patients. Eye protection is important due to the susceptibility of conjunctiva to viral transmission 14 Another method to reduce the viral load is the use of mouth rinses prior to surgery. The use of 1% hydrogen peroxide or 0.2% povidone iodine in addition to commonly used mouth rinses is recommended 19 .This reduces the salivary load of SARS-CoV-2 in patients as it appears be to be sensitive to oxidation and thus these mouthwashes can be used before procedure.

The surgeon must be careful while removing the PPE in order to prevent contamination of personal clothing and hand. Doffing procedure should be adequately performed and hand disinfection should be done after complete removal of PPE.

If possible, majority of the equipment inside the OR should be disposable. All other equipment and OR should be sterilized after surgery and such instruments should be handled as biohazardous. The waste material should be disposed-off in infectious-risk health waste (IRHW) containers.

For managing a particular fracture, calculated clinical decision based on clinical presentation, fracture pattern, invasiveness of operative procedure, condition of the patient, feasibility of secondary correction, risk-benefit ratio and availability of resources is required. If ORIF is necessary, then such fractures should be approached from a transcutaneous approach and intraoral incisions should be avoided. Mucosal incisions should be made with scalpel and electrocautery should be eluded. For hemostasis bipolar cautery should be used at lowest power setting 16 .Self-drilling screws should be used but if drilling is required, battery-powered lowspeed drill should be used with limited irrigation 16 . In maxilla Carroll-Girard screw should be considered for reduction if two point fixation provides acceptable stabilization 16 . Power saw should be replaced with osteotome in cases where osteotomy is required.

Nasal fractures should be urgently managed in case of uncontrollable active bleeding or septal hematoma. Naso-orbito-ethmoid fractures and grossly displaced nasal bone fractures results in disruption of bony morphology, which is difficult to restore when treatment is Patients with extensive soft tissue injuries, facial nerve transaction, contaminated lacerations, open fractures and those whose delayed management might compromise with patient's health and esthetics should be addressed emergently/urgently. A summery is provided in Table 1 .

Emergency and elective tracheostomy is a commonly performed procedure in oral and maxillofacial surgery. COVID-19 testing should be done in all patients prior to elective tracheostomy.

For emergency tracheostomy, when COVID-19 status of the patient is unknownor positive, all healthcare persons involved in tracheostomy should wear PPE including N95 masks, goggles, protective clothing, caps and gloves during the procedure. Open or percutaneous tracheostomy can be performed depending on the situation and discretion of the surgeon. An open tracheostomy, has less risk for aerosolization and is therefore preferred 10, 16 . Endotracheal tube should be advanced before the tracheostomy window is made and all precautions should be taken to avoid the piercing of cuff or tube. To prevent aerosolizing the virus a non-fenestrated tube with cuff should be used. Ventilation should be ceased before trachea is incised to prevent aerosolization and cuff should be checked before resuming ventilation 16 . Use of bipolar cautery and closed suctioning systems is preferred. Greater vigilance is required to prevent virus transmission from COVID 19 positive patients and therefore it is prudent to keep tracheostomy tube cuff properly inflated, performing in-line suctioning, maintaining a closed circuit, and rescheduling routine post-tracheostomy changes until COVID-19 status becomes negative 10, 23 .

COVID 19 positive/unconfirmed patients must be kept in isolation wards post-operatively.

Asymptomatic patients and COVID-19 negative patients should also be kept preferably isolated or at a distance from other patients during the current pandemic to reduce the risk of them getting infected and reducing cross-infection. Post-operatively, the surgeons should still wear masks, goggles, protective clothing and disposable gloves as patients infected with SARS-CoV-2 including asymptomatic virus carriers, can spread virus while coughing and sneezing. Thus, the respiratory secretions of the patient can be a potential source of infection for healthcare providers. Hand hygiene using alcoholic based hand scrubs and sanitizers before and after visiting the patient should be mandatory.

After discharging the patient, short term follow-ups of the patient should be avoided and telecommunication should be encouraged.

The current COVID-19 pandemic has taken a toll on the medical fraternity including the head and neck surgeons, who are at the top of the pyramid of healthcare professionals at risk of getting infected. The existing and future surgical practice needs to undergo some drastic changes in dealing with the patients while ensuring health safety for all including patients and healthcare providers. To provide the best care to the facial trauma patients, the surgeons have to make decisions regarding the treatment priority based on patients' condition and available resources.

There are various challenges as the patient handling has become strenuous.The surgeons need to abide by some principles like, properly assessing the risk, ensuring patient and healthcare provider safety, providing necessary and optimal care to the patient while preserving the vital resources, adopting a low-transmission approach, following personal safety using PPE, adopting proper hand hygiene, following universal precaution and practicing of work ethics. 

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Conflict of interest statement: The author declares no potential conflicts of interest with respect of research, authorship and/or publication of this article Funding: The author declares that there is no funding received