1 maxillofacial trauma management of traumatized patient
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Maxillofacial traumaMaxillofacial trauma
Management of Management of traumatized patienttraumatized patient
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Causes:Causes:
△△ Road traffic accident (RTA)Road traffic accident (RTA) 35-60% 35-60%
Rowe and Killey 1968; Rowe and Killey 1968; Vincent-Towned and Shepherd 1994Vincent-Towned and Shepherd 1994
△△ Fight and assault Fight and assault (interpersonal violence)(interpersonal violence)Most in economically prosperous countriesMost in economically prosperous countries
Beek and Merkx 1999Beek and Merkx 1999
△△ Sport and athletic injuriesSport and athletic injuries
△△ Industrial accidentsIndustrial accidents
△△ Domestic injuries and fallsDomestic injuries and falls
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Incidence Incidence
Literatures reported different Literatures reported different incidence in different parts of the incidence in different parts of the
WORLDWORLD and at different and at different TIMESTIMES
√ √ 11% in RTA (Oikarinen and Lindqvist 11% in RTA (Oikarinen and Lindqvist 1975)1975)
Mandible (61%)Mandible (61%) Maxilla (46%)Maxilla (46%) Zygoma (27%)Zygoma (27%) Nasal (19.5%)Nasal (19.5%)
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Factors affecting the high/low incidence of Factors affecting the high/low incidence of maxillofacial traumamaxillofacial trauma
GeographyGeography Fight, gunshot and RTA in developed and developing Fight, gunshot and RTA in developed and developing countries respectively (Papavassiliou 1990, Champion et al countries respectively (Papavassiliou 1990, Champion et al
1997)1997) Social factorsSocial factors
Violence in urban states (Telfer et al 1991; Hussain et al Violence in urban states (Telfer et al 1991; Hussain et al 1994; Simpson & McLean 1995)1994; Simpson & McLean 1995)
Alcohol and drugsAlcohol and drugs Yong men involved in RTA wile they are under alcohol or drug Yong men involved in RTA wile they are under alcohol or drug
effects (Shepherd 1994)effects (Shepherd 1994)
Road traffic legislationRoad traffic legislation Seat belts have resulted in dramatic decrease in injury (Thomas Seat belts have resulted in dramatic decrease in injury (Thomas
1990, as reflected in reduction in facial injury (Sabey et al 1977)1990, as reflected in reduction in facial injury (Sabey et al 1977)
SeasonSeason Seasonal variation in temperature zones (summer and snow and Seasonal variation in temperature zones (summer and snow and
ice in midwinter) of RTA, violence and sporting injuries (Hill et al ice in midwinter) of RTA, violence and sporting injuries (Hill et al 1998)1998)
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Assessment of Assessment of traumatized patienttraumatized patient
This should not concentrate This should not concentrate on the most obvious injury on the most obvious injury
but involve a rapid survey of but involve a rapid survey of the vital function to allow the vital function to allow
management prioritiesmanagement priorities
5% of all deaths world wide are caused by traumaThis might be much higher in this country
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Peaks of mortalityPeaks of mortality First peakFirst peak
Occurs within seconds of injury as a result of Occurs within seconds of injury as a result of irreversible brain or major vascular damageirreversible brain or major vascular damage
Second peakSecond peak
Occurs between a few minutes after injury and about Occurs between a few minutes after injury and about one hour later (golden hour)one hour later (golden hour)
Third peakThird peak
Occurs some days or weeks after injury as a result of Occurs some days or weeks after injury as a result of multi-organ failuremulti-organ failure
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Organization of trauma servicesOrganization of trauma services
Pre-hospital care (field triage)Pre-hospital care (field triage) Care delivered by fully trained paramedic in maintaining Care delivered by fully trained paramedic in maintaining
airway, controlling cervical spine, securing intravenous airway, controlling cervical spine, securing intravenous and initiating fluid resuscitationand initiating fluid resuscitation
Hospital care (inter-hospital triage)Hospital care (inter-hospital triage) Senior medical staff organized team to ensure that medical Senior medical staff organized team to ensure that medical
resources are deployed to maximum overall benefitresources are deployed to maximum overall benefit
Mass casualty triageMass casualty triage
triage decisions are crucial in triage decisions are crucial in determining individual patients survivaldetermining individual patients survival
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Primary surveyPrimary survey
ⒶⒶ Airway maintenance with cervical Airway maintenance with cervical spine controlspine control
ⒷⒷ Breathing and ventilationBreathing and ventilation
ⒸⒸ Circulation with hemorrhage controlCirculation with hemorrhage control
ⒹⒹ Disability assessment of Disability assessment of neurological statusneurological status
ⒺⒺ EExposure and complete examination xposure and complete examination of the patientof the patient
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AirwayAirway Satisfactory airway signifies the Satisfactory airway signifies the
implication of breathing and implication of breathing and ventilation and cerebral functionventilation and cerebral function
Management of maxillofacial trauma Management of maxillofacial trauma is an integral part in securing an is an integral part in securing an unobstructed airwayunobstructed airway
Immobilization in a natural position Immobilization in a natural position by a semi-rigid collar until damaged by a semi-rigid collar until damaged spine is excludedspine is excluded
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Is the patient fully conscious? And able to maintain adequate airway?
Semiconscious or unconscious patient rapidly suffocate because of inability to cough and adopt a posture that held tongue forward
Sequel of facial injurySequel of facial injury
Obstruction of airway
asphyxia
Cerebral hypoxia
Brain damage/ death
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Immediate treatment of airway obstruction in Immediate treatment of airway obstruction in facial injured patientfacial injured patient
△△Clearing of blood clot and mucous of the mouth and Clearing of blood clot and mucous of the mouth and nares and head position that lead to escape of nares and head position that lead to escape of secretions (sit-up or side position)secretions (sit-up or side position)
△△ Removal of foreign bodies as a broken denture or Removal of foreign bodies as a broken denture or avulsed teeth which can be inhaled and ensuring the avulsed teeth which can be inhaled and ensuring the patency of the mouth and oropharynexpatency of the mouth and oropharynex
△△ Controlling the tongue position in case of symphesial Controlling the tongue position in case of symphesial bilateral fracture of mandible and when voluntary bilateral fracture of mandible and when voluntary control of intrinsic musculature is lostcontrol of intrinsic musculature is lost
△△ Maintaining airway using artificial airway in Maintaining airway using artificial airway in unconscious patient with maxillary fracture or by unconscious patient with maxillary fracture or by nasophryngeal tube with periodic aspirationnasophryngeal tube with periodic aspiration
△△ Lubrication of patient’s lips and continuous Lubrication of patient’s lips and continuous supervisionsupervision
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Additional methods in preservation of the airway in Additional methods in preservation of the airway in patient with severe facial injuriespatient with severe facial injuries
Endotracheal intubationEndotracheal intubation Needed with multiple injuries, extensive soft tissue destruction and Needed with multiple injuries, extensive soft tissue destruction and
for serious injury that require artificial ventilationfor serious injury that require artificial ventilation
TracheostomyTracheostomy Surgical establishment of an opening into the tracheaSurgical establishment of an opening into the trachea Indications: Indications: 1. when prolonged artificial ventilation is necessary1. when prolonged artificial ventilation is necessary 2. to facilitate anesthesia for surgical repair in certain cases2. to facilitate anesthesia for surgical repair in certain cases 3. to ensure a safe postoperative recovery after extensive surgery3. to ensure a safe postoperative recovery after extensive surgery 4. following obstruction of the airway from laryngeal edema4. following obstruction of the airway from laryngeal edema 5. in case of serious hemorrhage in the airway5. in case of serious hemorrhage in the airway
CircothyroidectomyCircothyroidectomy An old technique associated with the risk of subglottic stenosis An old technique associated with the risk of subglottic stenosis
development particularly in children. The use of percutaneous development particularly in children. The use of percutaneous dilational treachestomy (PDT) in MFS is advocated by Ward Booth dilational treachestomy (PDT) in MFS is advocated by Ward Booth et al (1989) but it can be replaced with PDT.et al (1989) but it can be replaced with PDT.
Control of hemorrhage and Soft tissue lacerationControl of hemorrhage and Soft tissue laceration Repair, ligation, reduction of fracture and Postnasal packRepair, ligation, reduction of fracture and Postnasal pack
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Cervical spine injuryCervical spine injury
Can be deadly if it involved the Can be deadly if it involved the odontoid process of the axis bone of odontoid process of the axis bone of
the axis vertebrathe axis vertebra
If the injury above the clavicle bone, If the injury above the clavicle bone, clavicle collar should minimize the clavicle collar should minimize the
risk of any deteriorationrisk of any deterioration
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Breathing and ventilationBreathing and ventilation Chest injuries:Chest injuries:
Pneumothorax, haemopneumothorax, flail Pneumothorax, haemopneumothorax, flail segments, reputure daiphram, cardiac segments, reputure daiphram, cardiac
tamponadetamponade
signssigns
Clinical Deviated trachea
Absence of breath sounds
Dullness to percussionParadoxical movements
Hyper-response with a large pneumothoraxMuffled heart sounds
RadiographicalLoss of lung markingDeviation of trachea
Raised hemi-diaphragmFluid levels
Fracture of ribs
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Emergency treatment in case Emergency treatment in case of chest injuryof chest injury
Occluding of open chest woundsOccluding of open chest wounds
Endotreacheal intubation for unstable flail Endotreacheal intubation for unstable flail chestchest
Intermittent positive pressure ventilationIntermittent positive pressure ventilation
Needle decompression of the pericardiumNeedle decompression of the pericardium
Decompression of gastric dilation and Decompression of gastric dilation and aspiration of stomach contentaspiration of stomach content
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Circulation Circulation
Circulatory collapse leads to low Circulatory collapse leads to low blood pressure, increasing pulse rate blood pressure, increasing pulse rate and diminished capillary filling at the and diminished capillary filling at the
peripheryperiphery
Patient resuscitationPatient resuscitationRestoration of cardio-respiratory functionRestoration of cardio-respiratory function
Shock managementShock managementReplacement of lost fluidReplacement of lost fluid
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Fluid for resuscitation:Fluid for resuscitation:☞☞Adequate venous access at two pointsAdequate venous access at two points
☞☞ Hypotension assumed to be due to Hypotension assumed to be due to hypovolaemiahypovolaemia
☞☞ Resuscitation fluid can be crystalloid, colloid Resuscitation fluid can be crystalloid, colloid or blood; or blood; ringer lactateringer lactate
☞☞ Surgical shock requires blood transfusion, Surgical shock requires blood transfusion, preferably with cross matching or group O+preferably with cross matching or group O+
☞☞ Urine output must be monitored as an Urine output must be monitored as an indicator of cardiac out putindicator of cardiac out put
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Reduction and fixation will often arrest Reduction and fixation will often arrest bleeding of long durationbleeding of long duration
Pulse and blood pressure should be Pulse and blood pressure should be monitored and appropriate monitored and appropriate
replacement therapy is to be startedreplacement therapy is to be started
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Neurological deficientNeurological deficient
Rapid assessment of neurological disability is made Rapid assessment of neurological disability is made by noting the patient response on four points scale:by noting the patient response on four points scale:
A Response appropriately, is AwareA Response appropriately, is Aware
V Response to verbal stimuliV Response to verbal stimuli
P Response to painful stimuliP Response to painful stimuli
U Does not responds, UnconsciousU Does not responds, Unconscious
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Glasgow coma scale (GCS)Glasgow coma scale (GCS)(Teasdale and Jennett, 1974)(Teasdale and Jennett, 1974)
Eye Eye openingopening
Motor Motor responseresponse
Verbal Verbal responseresponse
SpontaneousSpontaneous 44 Move to Move to commandcommand
66 ConverseConverse 55
To speechTo speech 33 Localizes to Localizes to painpain
55 ConfusedConfused 44
To painTo pain 22 Withdraw Withdraw from painfrom pain
44 GibberishGibberish 33
nonenone 11 flexesflexes 33 gruntsgrunts 22
ExtendsExtends 22 nonenone 11nonenone 11
Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15
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Exposure Exposure
All trauma patient must be fully All trauma patient must be fully exposed in a warm environment to exposed in a warm environment to disclose any other hidden injuriesdisclose any other hidden injuries
When the airway is adequately When the airway is adequately secured the second survey of the secured the second survey of the whole body is to be carried out for:whole body is to be carried out for:
Accurate diagnosisAccurate diagnosis Maintenance of a stable stateMaintenance of a stable state Determination of priorities in treatmentDetermination of priorities in treatment Appropriate specialist referralAppropriate specialist referral
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Secondary surveySecondary survey
Although maxillofacial injuries is part of the Although maxillofacial injuries is part of the secondary survey, OMFS might be involved at secondary survey, OMFS might be involved at
early stage if the airway is compromised by early stage if the airway is compromised by direct facial traumadirect facial trauma
Head injuryHead injury Abdominal injuryAbdominal injury Injury to extremitiesInjury to extremities
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Head injuryHead injury
Many of facial injury patients sustain head Many of facial injury patients sustain head injury in particular the mid face injuriesinjury in particular the mid face injuries
OpenOpen
Closed Closed
it is ranged from Mild concussion to brain it is ranged from Mild concussion to brain deathdeath
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Signs and symptoms of head injurySigns and symptoms of head injury Loss of consciousLoss of conscious OROR History of loss of consciousHistory of loss of conscious History of vomitingHistory of vomiting Change in pulse rate, blood pressure and Change in pulse rate, blood pressure and
pupil reaction to light in association with pupil reaction to light in association with increased intracranial pressureincreased intracranial pressure
Assessment of head injury (behavioral Assessment of head injury (behavioral responses “motor and verbal responses” responses “motor and verbal responses” and eye opening)and eye opening)
Skull fractureSkull fracture Skull base fracture (battle’s sign)Skull base fracture (battle’s sign) Temporal/ frontal bone fractureTemporal/ frontal bone fracture Naso-orbital ethmoidal fractureNaso-orbital ethmoidal fracture
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slow reaction and fixation of dilated slow reaction and fixation of dilated pupil denotes a rise in intra-cranial pupil denotes a rise in intra-cranial
pressurepressure
Rise in intercranial pressure as a result Rise in intercranial pressure as a result of acute subdural or extradural of acute subdural or extradural
hemorrhage deteriorate the patient’s hemorrhage deteriorate the patient’s neurological statusneurological status
Apparently stable patient with suspicion of Apparently stable patient with suspicion of head injury must be monitored at intervals up head injury must be monitored at intervals up
to one hour for 24 hour after the traumato one hour for 24 hour after the trauma
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Hemorrhage Hemorrhage
Acute bleeding may lead to hemorrhagic Acute bleeding may lead to hemorrhagic shock and circulatory collapseshock and circulatory collapse
Abdominal and pelvis injury; liver and Abdominal and pelvis injury; liver and internal organs injury internal organs injury (peritonism)(peritonism)
Fracture of the extremities (femur)Fracture of the extremities (femur)
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Abdomen and pelvisAbdomen and pelvis
In addition to direct injuries, loss of In addition to direct injuries, loss of circulating blood into peritoneal circulating blood into peritoneal
cavity or retroperitonial space is life cavity or retroperitonial space is life threatening, indicated by physical threatening, indicated by physical
signs and palpation, percussion and signs and palpation, percussion and auscultationauscultation
Management:Management: Diagnostic peritoneal lavage (DPL) to Diagnostic peritoneal lavage (DPL) to
detect blood, bowel content, urinedetect blood, bowel content, urine Emergency laprotomyEmergency laprotomy
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Extremity traumaExtremity trauma
Fracture of extremities in particular Fracture of extremities in particular the femur can be a significant cause the femur can be a significant cause of occult blood loss. Straightening of occult blood loss. Straightening and reduction of gross deformity is and reduction of gross deformity is
part of circulation controlpart of circulation control
Cardinal features of extremities injuryCardinal features of extremities injury Impaired distal perfusion (risk of ischemia)Impaired distal perfusion (risk of ischemia) Compartment syndrome (limb loss)Compartment syndrome (limb loss) Traumatic amputation Traumatic amputation
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Patient hospitalization and Patient hospitalization and determination of prioritiesdetermination of priorities
Facial bone fracture is hardly ever an urgent Facial bone fracture is hardly ever an urgent procedure,procedure,
simple and minor injury of ambulant patient may simple and minor injury of ambulant patient may occasionally mask a serious injury that eventually occasionally mask a serious injury that eventually
ended the patient’s lifeended the patient’s life
△ △ emergency cases require instant admissionemergency cases require instant admission
△ △ conditions that may progress to emergencyconditions that may progress to emergency
△ △ cases with no urgencycases with no urgency
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Preliminary treatment in complex Preliminary treatment in complex facial injuryfacial injury
Soft tissue lacerationSoft tissue laceration (8 hours of injury with no (8 hours of injury with no delay beyond 24 hours)delay beyond 24 hours)
Support of the bone fragmentsSupport of the bone fragments
Injury to the eyeInjury to the eye As a result of trauma, 1.6 million are blind, 2.3 As a result of trauma, 1.6 million are blind, 2.3
million are suffering serious bilateral visual million are suffering serious bilateral visual impairment and 19 million with unilateral loss of impairment and 19 million with unilateral loss of sight (Macewen 1999)sight (Macewen 1999)
Ocular damageOcular damage Reduction in visual acuityReduction in visual acuity Eyelid injuryEyelid injury
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Prevention of infectionPrevention of infectionFractures of jaw involving teeth bearing areas Fractures of jaw involving teeth bearing areas are compound in nature and midface fracture are compound in nature and midface fracture
may go high, leading to CSF leaks may go high, leading to CSF leaks (rhinorrhoea, otorrhoea) and risk of meningitis,(rhinorrhoea, otorrhoea) and risk of meningitis,
and in case of perforation of cartilaginous and in case of perforation of cartilaginous auditory canalauditory canal
DiagnosisDiagnosis: : Laboratory investigation, CT and MRI scanLaboratory investigation, CT and MRI scan Management:Management:
• Dressing of external woundsDressing of external wounds• Closure of open woundsClosure of open wounds• Reposition and immobilization of the fracturesReposition and immobilization of the fractures• Repair of the dura matterRepair of the dura matter• Antibacterial prophylaxis (as part of the general management Antibacterial prophylaxis (as part of the general management
(Eljamal, 1993)(Eljamal, 1993)
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Control of painControl of pain Displaced fracture may cause severe pain but Displaced fracture may cause severe pain but
strong analgesic ( Morphine and its derivatives) strong analgesic ( Morphine and its derivatives) must be avoided as they depress cough reflex, must be avoided as they depress cough reflex, constrict pupils as they may mask the signs of constrict pupils as they may mask the signs of
increasing intracranial pressureincreasing intracranial pressure
Management:Management:
☞ ☞ Non-steroidal anti-inflammatory drugs can Non-steroidal anti-inflammatory drugs can be prescribed (Diclofenac acid)be prescribed (Diclofenac acid)
☞☞ Reduction of fractureReduction of fracture
☞☞ sedationsedation
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In patient careIn patient care
Necessary medicationsNecessary medications
Diet (fluid, semi-fluid and solid food) Diet (fluid, semi-fluid and solid food) intake and output (fluid balance intake and output (fluid balance chart)chart)
Hygiene and physiotherapy Hygiene and physiotherapy
Proper timing for surgical Proper timing for surgical interventionintervention
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