A Multidisciplinary Approach and Review of Safety Recommendations for Plastic Surgeons During the COVID-19 Pandemic

Are N95 Masks Enough?

Scharukh Jalisi, M.D., M.A.; Austin D. Chen, M.D.; Ernest Gomez, M.D.; Radhika Chigurupati, D.M.D.; Ryan Cauley, M.D., M.P.H.; Suzanne Olbricht, M.D.; Bernard T. Lee, M.D., M.B.A., M.P.H.; Samuel J. Lin, M.D., M.B.A.

Disclosures

Plast Reconstr Surg. 2021;148(2):467-474. 

In This Article

Emergency Room Evaluation

A triage telephone line should be established for daily dental or oral surgery emergencies with the ability for remote telemedicine visit by the health care provider for a higher level of consultation, eliminating in-person visits unless deemed urgent or emergent.[4,5] Urgent care examples include acute dental abscess, acute facial or neck swelling, trismus or difficulty opening the mouth, pain while swallowing, bleeding from the oral cavity, or acute oral mucosa swelling because of allergic reaction and maxillofacial injuries.[21–23] Mucosal lesions/injuries can have high aerosolizing potential, and any in-person visits require full personal protective equipment, including N95 mask, face shield, gown, and gloves. The patient should be evaluated by the most experienced provider to minimize exposure time to the provider. A negative-pressure room should be used for procedures such as dental extractions or transoral incision and drainage of an abscess, or dentoalveolar fractures.

Many providers in plastic surgery are involved with the management of facial trauma. Patients with mucosal injuries have a higher risk of aerosolization of their mucus and pose a transmission threat to the provider.[1,5] As with any high-risk evaluation, the provider must examine such patients with full personal protective equipment, including N95 masks, eye protection, gown, and gloves, because of the high risk of aerosolization. Patients with extensive injuries should have their airway secured early with the assistance of anesthesia to minimize aerosolization for all providers.

Burn injuries often present with concurrent traumatic injuries, including those to the neck and airway. The assessment of a patient with burn injuries should always begin with the standard trauma survey. Those with major burns, especially airway injuries, are at high risk of requiring airway support. The provider must examine such patients with full personal protective equipment, including N95 masks, eye protection, gown, and gloves, because of the high risk of aerosolization. Patients with extensive burns or airway injuries should be intubated early, ideally with the assistance of anesthesia or another experienced provider, to minimize viral transmission risk. Burns involving a large total body surface area (over 50 percent) can be associated with hemodynamic instability, fluid overload, pulmonary injury, sepsis, and acute compromise of the immune system, all of which can complicate their critical care management. The presence of an acute COVID-19 infection in a burn-injured patient would likely further complicate the course, putting them at high-risk of a poor pulmonary outcome. It is of utmost importance to reduce the risk of viral transmission to burn-injured patients without acute infection from COVID-19, and to anticipate the challenging clinical course of a patient with these concurrent diagnoses. It is advisable to proceed early with a lung protective ventilation strategy and judicious fluid management to maximize oxygenation and minimize fluid creep.

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