Patients with severe facial fractures will usually have a decreased level of consciousness due to intracranial injury. Neck fracture is also common in these patients. Facial fractures sufficient to put the airway at risk will almost always be unstable. Palpate the jaw for crepitance and instability. Grasp the upper teeth between your thumb and knuckle of your index finger and test for maxillary instability.
Bilateral eyelid swelling and a sunken facial appearance suggest a cranio-facial fracture.
The diagnosis of risk to the airway is made based on the finding of significant fracturing and soft tissue injury. If trauma involves both the mandible and upper face, and the C-spine is still at risk, you are probably better off performing cricothyrotomy. If the C-spine is OK, oral intubation may be attempted first. Nasal intubation may cause complications such as entry into open fractures, and may restart bleeding into the airway. Gastric tubes may be passed orally in the presence of facial trauma.