Facial Trauma and the Airway
Objective: Keep a facial-trauma airway open with suction and position. If the patient can protect their own airway and your protocol allows it, sit them up so blood can drain. Do not force a nasopharyngeal airway through an injured midface.
Why this matters
A broken midface bleeds into the airway. If you lay the patient flat for a collar, that blood can fill the airway. Suction and position come first. Spinal motion restriction (SMR) should not cost the airway. Blood flow still matters. Use a board for the move, then take the patient off the board. Use a collar only if your protocol says so.
- Turn suction on and test it before you need it. Teeth and blood will keep coming.
- If your protocol allows the patient to sit up during SMR, use that position so blood can drain. Do not lay a gurgling patient flat only to place a collar.
- A nasopharyngeal airway (NPA) through a possible cribriform-plate or midface injury is a protocol caution. The cribriform plate is the thin bone at the roof of the nose. See the oropharyngeal airway (OPA) and NPA lesson.
- Suction is on and tested.
- Sit them up if protocol allows, so blood can drain.
- Do not force an NPA through an injured midface unless protocol says so.
Clinical sequence
- Turn suction on and test it. Blood and teeth will keep filling the airway. Suction is the first move.
- If protocol allows sitting SMR, sit the patient up so blood can drain. Do not lay them flat for a collar while they are gurgling.
- Do not force an NPA through a possible cribriform-plate or midface fracture unless your protocol allows it.
Teaching points
- Position: use a recovery position or sitting if the spine story allows it. Flat on a board with a bleeding face means you will be suctioning the whole way.
- Airway tools: use an oropharyngeal airway (OPA) if there is no gag. A supraglottic airway (SGA) may be the backup when direct laryngoscopy (DL) is flooded with blood. Still confirm the SGA with a carbon-dioxide waveform.
- NPA caution: do not force an NPA when you see midface injury or basilar-skull signs. Those signs include bruising around both eyes, bruising behind the ear (Battle's sign), and clear fluid that may be cerebrospinal fluid.
- The cervical spine still matters when the mechanism says so. Do not let the board or the collar become the reason the patient cannot breathe.
Common errors
- Forcing an NPA through an unstable midface.
- Having no suction ready when the mouth fills with blood.
- Laying the patient flat for a collar while they gurgle.
Practice
One-minute check
A motorcyclist has a broken midface, is gurgling, and has a Glasgow Coma Scale (GCS) score of 8. Say the position, the suction plan, and the next airway tool you will reach for. Say what you will not pass through the nose.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol decides
- DAS guidelines hub — blood and trauma make a difficult airway — plan B
- AHA 2025 Part 7 — suction and open the airway so ventilation works
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.