Transcript Management of maxillofacial trauma

Maxillofacial trauma
Management of
traumatized patient
1
Causes:
△ Road traffic accident (RTA)
35-60%
Rowe and Killey 1968;
Vincent-Towned and Shepherd 1994
△ Fight and assault
(interpersonal violence)
Most in economically prosperous countries
Beek and Merkx 1999
△ Sport and athletic injuries
△ Industrial accidents
△ Domestic injuries and falls
2
Incidence
Literatures reported different
incidence in different parts of the
WORLD and at different TIMES
√ 11% in RTA (Oikarinen and Lindqvist
1975)
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Mandible (61%)
Maxilla (46%)
Zygoma (27%)
Nasal (19.5%)
3

Factors affecting the high/low incidence of
maxillofacial trauma
Geography
Fight, gunshot and RTA in developed and developing
countries respectively (Papavassiliou 1990, Champion et al
1997)

Social factors
Violence in urban states (Telfer et al 1991; Hussain et al
1994; Simpson & McLean 1995)

Alcohol and drugs
Yong men involved in RTA wile they are under alcohol or drug
effects (Shepherd 1994)
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Road traffic legislation
Seat belts have resulted in dramatic decrease in injury (Thomas
1990, as reflected in reduction in facial injury (Sabey et al 1977)

Season
Seasonal variation in temperature zones (summer and snow and
ice in midwinter) of RTA, violence and sporting injuries (Hill et al4
1998)
Assessment of
traumatized patient
This should not concentrate
on the most obvious injury
but involve a rapid survey of
the vital function to allow
management priorities
5% of all deaths world wide are caused by trauma
This might be much higher in this country
5
Peaks of mortality

First peak
Occurs within seconds of injury as a result of
irreversible brain or major vascular damage

Second peak
Occurs between a few minutes after injury and about
one hour later (golden hour)

Third peak
Occurs some days or weeks after injury as a result of6
multi-organ failure
Organization of trauma services
triage decisions are crucial in
determining individual patients survival

Pre-hospital care (field triage)
Care delivered by fully trained paramedic in maintaining
airway, controlling cervical spine, securing intravenous and
initiating fluid resuscitation

Hospital care (inter-hospital triage)
Senior medical staff organized team to ensure that medical
resources are deployed to maximum overall benefit

Mass casualty triage
7
Primary survey
Ⓐ Airway maintenance with cervical
spine control
Ⓑ Breathing and ventilation
Ⓒ Circulation with hemorrhage control
Ⓓ Disability assessment of neurological
status
Ⓔ Exposure and complete examination
of the patient
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Airway
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Satisfactory airway signifies the
implication of breathing and
ventilation and cerebral function
Management of maxillofacial trauma
is an integral part in securing an
unobstructed airway
Immobilization in a natural position
by a semi-rigid collar until damaged
spine is excluded
9
Sequel of facial injury
Obstruction of airway
asphyxia
Cerebral hypoxia
Brain damage/ death
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
10
Immediate treatment of airway obstruction in
facial injured patient
△Clearing of blood clot and mucous of the mouth and
nares and head position that lead to escape of
secretions (sit-up or side position)
△ Removal of foreign bodies as a broken denture or
avulsed teeth which can be inhaled and ensuring the
patency of the mouth and oropharynex
△ Controlling the tongue position in case of symphesial
bilateral fracture of mandible and when voluntary
control of intrinsic musculature is lost
△ Maintaining airway using artificial airway in
unconscious patient with maxillary fracture or by
nasophryngeal tube with periodic aspiration
△ Lubrication of patient’s lips and continuous
supervision
11
Additional methods in preservation of the airway in
patient with severe facial injuries
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Endotracheal intubation
Needed with multiple injuries, extensive soft tissue destruction
and for serious injury that require artificial ventilation
Tracheostomy
Surgical establishment of an opening into the trachea
Indications: 1. when prolonged artificial ventilation is necessary
2.
3.
4.
5.
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to facilitate anesthesia for surgical repair in certain cases
to ensure a safe postoperative recovery after extensive surgery
following obstruction of the airway from laryngeal edema
in case of serious hemorrhage in the airway
Circothyroidectomy
An old technique associated with the risk of subglottic stenosis
development particularly in children. The use of percutaneous
dilational treachestomy (PDT) in MFS is advocated by Ward Booth
et al (1989) but it can be replaced with PDT.
Control of hemorrhage and Soft tissue laceration
Repair, ligation, reduction of fracture and Postnasal pack
12
Cervical spine injury
Can be deadly if it involved the
odontoid process of the axis bone of
the axis vertebra
If the injury above the clavicle bone,
clavicle collar should minimize the
risk of any deterioration
13
Breathing and ventilation

Chest injuries:
Pneumothorax, haemopneumothorax, flail
segments, reputure daiphram, cardiac
tamponade
signs
Clinical
Deviated trachea
Absence of breath
sounds
Dullness to percussion
Paradoxical movements
Hyper-response with
a large pneumothorax
Muffled heart sounds
Radiographical
Loss of lung marking
Deviation of trachea
Raised hemi-diaphragm
Fluid levels
Fracture of ribs
14
Emergency treatment in case
of chest injury

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Occluding of open chest wounds
Endotreacheal intubation for unstable flail
chest
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Intermittent positive pressure ventilation
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Needle decompression of the pericardium
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Decompression of gastric dilation and
aspiration of stomach content
15
Circulation
Circulatory collapse leads to low
blood pressure, increasing pulse rate
and diminished capillary filling at the
periphery
Patient resuscitation
Restoration of cardio-respiratory function
Shock management
Replacement of lost fluid
16
Fluid for resuscitation:
☞Adequate venous access at two points

☞ Hypotension assumed to be due to
hypovolaemia
☞ Resuscitation fluid can be crystalloid,
colloid or blood; ringer lactate
☞ Surgical shock requires blood transfusion,
preferably with cross matching or group O+
☞ Urine output must be monitored as an
indicator of cardiac out put
17
Reduction and fixation will often arrest
bleeding of long duration
Pulse and blood pressure should be
monitored and appropriate
replacement therapy is to be started
18
Neurological deficient
Rapid assessment of neurological disability is made
by noting the patient response on four points scale:

A
Response appropriately, is Aware

V
Response to verbal stimuli
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P
Response to painful stimuli
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U
Does not responds, Unconscious
19
Glasgow coma scale (GCS)
(Teasdale and Jennett, 1974)
Eye
opening
Motor
response
Verbal
response
Spontaneous 4 Move to
command
6 Converse
5
To speech
3 Localizes to
pain
5 Confused
4
To pain
2 Withdraw
from pain
4 Gibberish
3
none
1 flexes
3 grunts
2
Extends
2
none
1
none
1
Score 8 or less indicates poor prognosis, moderate head injury
between 9-12 and mild refereed to 13-15
20
Exposure
All trauma patient must be fully
exposed in a warm environment to
disclose any other hidden injuries
When the airway is adequately
secured the second survey of the
whole body is to be carried out for:
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Accurate diagnosis
Maintenance of a stable state
Determination of priorities in treatment
Appropriate specialist referral
21
Secondary survey
Although maxillofacial injuries is part of the
secondary survey, OMFS might be involved at
early stage if the airway is compromised by
direct facial trauma
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Head injury
Abdominal injury
Injury to extremities
22
Head injury
Many of facial injury patients sustain head
injury in particular the mid face injuries

Open

Closed
it is ranged from Mild concussion to brain
death
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Signs and symptoms of head injury
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Loss of conscious
OR
History of loss of conscious
History of vomiting
Change in pulse rate, blood pressure and
pupil reaction to light in association with
increased intracranial pressure
Assessment of head injury (behavioral
responses “motor and verbal responses”
and eye opening)
Skull fracture
Skull base fracture (battle’s sign)
Temporal/ frontal bone fracture
Naso-orbital ethmoidal fracture
24
slow reaction and fixation of dilated
pupil denotes a rise in intra-cranial
pressure
Rise in intercranial pressure as a result
of acute subdural or extradural
hemorrhage deteriorate the patient’s
neurological status
Apparently stable patient with suspicion of head
injury must be monitored at intervals up to
one hour for 24 hour after the trauma
25
Hemorrhage
Acute bleeding may lead to hemorrhagic
shock and circulatory collapse
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Abdominal and pelvis injury; liver and
internal organs injury (peritonism)
Fracture of the extremities (femur)
26
Abdomen and pelvis
In addition to direct injuries, loss of
circulating blood into peritoneal
cavity or retroperitonial space is life
threatening, indicated by physical
signs and palpation, percussion and
auscultation
Management:
 Diagnostic peritoneal lavage (DPL) to
detect blood, bowel content, urine
 Emergency laprotomy
27
Extremity trauma
Fracture of extremities in particular
the femur can be a significant cause
of occult blood loss. Straightening
and reduction of gross deformity is
part of circulation control
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Cardinal features of extremities injury
Impaired distal perfusion (risk of
ischemia)
Compartment syndrome (limb loss)
Traumatic amputation
28
Patient hospitalization and
determination of priorities
Facial bone fracture is hardly ever an urgent
procedure,
simple and minor injury of ambulant patient may
occasionally mask a serious injury that eventually
ended the patient’s life
△ emergency cases require instant admission
△ conditions that may progress to emergency
△ cases with no urgency
29
Preliminary treatment in complex
facial injury

Soft tissue laceration (8 hours of injury with no
delay beyond 24 hours)
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Support of the bone fragments
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Injury to the eye
As a result of trauma, 1.6 million are blind, 2.3
million are suffering serious bilateral visual
impairment and 19 million with unilateral loss of
sight (Macewen 1999)
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Ocular damage
Reduction in visual acuity
Eyelid injury
30
Prevention of infection
Fractures of jaw involving teeth bearing areas
are compound in nature and midface fracture
may go high, leading to CSF leaks
(rhinorrhoea, otorrhoea) and risk of meningitis,
and in case of perforation of cartilaginous
auditory canal
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Diagnosis:
Laboratory investigation, CT and MRI scan
Management:
•
•
•
•
•
Dressing of external wounds
Closure of open wounds
Reposition and immobilization of the fractures
Repair of the dura matter
Antibacterial prophylaxis (as part of the general management
31
(Eljamal, 1993)
Control of pain
Displaced fracture may cause severe pain but
strong analgesic ( Morphine and its derivatives)
must be avoided as they depress cough reflex,
constrict pupils as they may mask the signs of
increasing intracranial pressure
Management:
☞ Non-steroidal anti-inflammatory drugs can
be prescribed (Diclofenac acid)
☞ Reduction of fracture
☞ sedation
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In patient care
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Necessary medications
Diet (fluid, semi-fluid and solid food)
intake and output (fluid balance
chart)
Hygiene and physiotherapy
Proper timing for surgical
intervention
33