Transcript Face_Neck_Trauma

FACE, NECK, & EYE
INJURY
WHY?
• Body armor works
– 9% mortality of injuries, compared to 24% in
Vietnam or 30% in WWII
• Improved compliance with Kevlar wear
• Remaining exposed areas are face, neck,
and extremities
– 22% of wounded with brain/head/neck injury,
compared to 12% in Vietnam
ANATOMY
• Soft Tissues
– Includes parotid glands
• Bones
– Facial and cervical spine
• Neck blood vessels
– Carotid and vertebral arteries
– Jugular and other veins
• Trachea
• Esophagus
• Globes and surrounding ducts
ABC’s REMAIN BASIC!
• Soft tissue or bony injuries may immediately threaten
the airway
– Uncontrolled bleeding can change “stable” to “unstable” very
quickly
– Standard maneuvers may be less successful in setting of
fractures, etc.
• Associated brain or spine injuries may cause airway
loss as well
– All blunt face/neck trauma must be considered at risk for Cspine injury
– Neurologic injuries may worsen with time as well
TRACHEAL INJURIES
• Securing the airway remains critical
• Tracheal injuries may cause significant air leak
– Pneumomediastinum
– Pneumothorax, even tension pneumothorax
• Surgical repair is required
– If unavailable, manage with secure airway and chest tubes if
necessary
– Minimize airway pressure on ventilator
BLUNT TRACHEAL INJURY
Pneumothorax and
Pneumomediastinum
Tracheal Injury
EPISTAXIS
• May result in significant
bleeding
• Separated into anterior
and posterior sources
• Intubation for airway
control prior to packing
may be needed
EPISTAXIS
Posterior Packing
EPISTAXIS
Anterior Packing
Epistat Balloon
ZONES OF THE NECK
ZONE 1 INJURY
• Difficult to access from neck incision, may need
sternotomy/thoracotomy
• Initial management with angio/CT angio,
bronchoscopy, esophagoscopy
– Basically need to evaluate all vascular and aerodigestive
structures potentially in harm’s way
• As with most trauma, “stable or unstable” guides the
initial management
– Active bleeding, expanding hematomas, or hemodynamic
instability need to be addressed first in the OR and then with
staged work up if indicated
ZONE 2 INJURY
• Only zone that is easily accessed from a neck
incision
• Still requires investigation of vascular and
aerodigestive structures
• In a STABLE patient, can be investigated with CT
and endoscopy potentially
• Again, unstable patients or those with active bleeding
issues need to be addressed in the operating room!
ZONE 3 INJURY
• Similar to Zone I, potentially difficult to access
surgically and so angiography or CT needed, with
possible endoscopy
– These tend to be vascular injuries at the skull base that are
very difficult to control surgically
• Again, instability should prompt rapid damage control
in OR, followed by additional work up if needed
STAB WOUND - CCA
VASCULAR INJURY
COMPLICATIONS
• Hemorrhage is the
first concern
• Stroke is the second
concern (up to 25%
of ICA injuries)
• Revascularization
may be required
ICA/ECA Injury with Reconstruction
BLUNT CEREBROVASCULAR
INJURY
• More frequent that was believed in the past
– Roughly 1-1.5% of blunt admissions
• Workup with CT Angio or conventional angiography
• Treatment based on grade
– Low grade lesions no intervention or ASA
– Higher grade lesions need anticoagulation or possibly
stenting, with recent interest in aggressive antiplatelet
agents
• Complications related to increased stroke risk
BLUNT CEREBROVASCULAR
GRADES
FACIAL FRACTURES
• Frequent injuries, but rarely have to be addressed
immediately from a surgical standpoint
• The primary question should be one of airway
protection
– The anatomic disruption or bleeding may cause loss of
airway
– The situation may deteriorate as swelling progresses in the
upper airway
• Remember that the globes may be injured by
fractures and a good exam, including visual acuity, is
mandatory
UPPER FACE FRACTURES
• Clinical exam is very
useful – pain, bruising,
crepitance, movement
• Malocclusion often
occurs with mandible
fractures
• Check a cranial nerve
exam!
LE FORT FRACTURES
MANDIBLE FRACTURES
• Malocclusion a common
hint on exam
• 50% will break multiple
places
• Can be managed with
soft diet/liquids and pain
control in short term
• Operative repair
ultimately required
Panorex
FACIAL FRACTURES
• Open fractures may require broad spectrum
antibiotic coverage
– This isn’t agreed upon, but if a sinus is violated
then initial coverage is reasonable
• Remember that if enough trauma occurred to
fracture bones, the nearby structures are also
at risk
– At least 20% of facial fractures will have a TBI
– About 2% will have a C-spine fracture
OCULAR INJURIES
• Evaluation requires a
careful exam, including
visual acuity
• Open globes are as
emergent as threatened
limbs, and need
antibiotic coverage like
open fractures
• Remember that open
globes need an altitude
restriction for
MEDEVAC
OCULAR INJURIES
• Layering of blood in the
inferior anterior
chamber
• Usually managed with
rest, elevation of HOB,
and correction of
clotting factors
• 5% will require surgical
evacuation
Hyphema
OCULAR INJURIES
• Minor injury
• Resolves
spontaneously, though
may take weeks
• Avoid anticoagulant or
antiplatelet drugs
• Lubricant eye drops as
needed
Subconjunctival hemorrhage
SUMMARY
• Airway control remains the primary concern
• Control of hemorrhage may require packing, angiography,
or operation
• Facial fracture repair may be delayed if necessary once
wounds are closed
• Tracheal and esophageal injuries require more urgent
repair
• Globe injuries should be considered with facial fractures,
and known injuries treated with the same urgency as
threatened limbs
QUESTIONS