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)

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)
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

E xposure and complete examination

of the patient
8
 Airway
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 patients lips and continuous

supervision
11
 Additional methods in preservation of the airway in
patient with severe facial injuries
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. to facilitate anesthesia for surgical repair in certain cases
3. to ensure a safe postoperative recovery after extensive surgery
4. following obstruction of the airway from laryngeal edema
5. 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
Radiographical
Absence of breath
Loss of lung marking
sounds
Deviation of trachea
Dullness to percussion
Raised hemi-diaphragm
Paradoxical movements
Fluid levels
Hyper-response with
Fracture of ribs
a large pneumothorax
Muffled heart sounds 14
 Emergency treatment in case
of chest injury

Occluding of open chest wounds

Endotreacheal intubation for unstable flail

chest

Intermittent positive pressure ventilation

Needle decompression of the pericardium

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

P Response to painful stimuli

U Does not responds, Unconscious

19
 Glasgow coma scale (GCS)
(Teasdale and Jennett, 1974)
Eye Motor Verbal
opening response response
Spontaneous 4 Move to 6 Converse 5
command
To speech 3 Localizes to 5 Confused 4
pain
To pain 2 Withdraw 4 Gibberish 3
from pain
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:

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
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
23
Signs and symptoms of head injury
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 (battles 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 patients
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

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

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 patients 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)

Support of the bone fragments

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)
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
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
(Eljamal, 1993) 31
 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
32

sedation
 In patient care
Necessary medications

Diet (fluid, semi-fluid and solid food)

intake and output (fluid balance
chart)

Hygiene and physiotherapy

Proper timing for surgical

intervention
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Thank you