Emergency management of patient in Oral & Maxillofacial Surgery:The Golden Hour

Presented by :Dr. Sujay PatilM.D.S Part I

Contents

Introduction The Golden Hour Trauma care staging Pre hospital stage B.L.S Triage Preparation at receiving hospital Initial assessment of the patient Primary survey and Resuscitation A.T.L.S Secondary survey Maxillofacial aspects

Introduction

Of all trauma deaths, 50% occur within minutes at the site of the accident. However statistically for every trauma death 200 other patients sustain injuries requiring medical attention and of these 24 will require hospitalisation.

In an article published in The Times of India, according to a WHO survey, India leads the world in road deaths. Around 1,50,000 people lose there lives every year in RTA’s, which they say is actually half the number because of many unaccounted deaths. Half a million people receive serious but non fatal injuries.

Andhra pradesh followed by Maharashtra are the states leading in RTA deaths.

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Causes of Maxillofacial trauma

△ Road traffic accident (RTA) 35-60%

Rowe and Killey 1968; Vincent-Towned and Shepherd 1994

△ Fight and assault (interpersonal violence)

△ Sport and athletic injuries

△ Industrial accidents

△ Domestic injuries and falls

The Golden Hour

Origin of the term

Late Dr. R Adams Cowley is credited with promoting this concept, first in his capacity as a military surgeon and later as head of the University of Maryland Shock Trauma Center.

The concept of the "Golden Hour" may have been derived from French military World War I data .

The Golden Hour

The R Adams Cowley Shock Trauma Center section of the University of Maryland Medical Center’s website quotes Cowley as saying, "There is a golden hour between life and death. If a patient is critically injured he has less than 60 minutes to survive. He may not die right then; it may be a few days, weeks, a month or a year later -- but something has happened in its body that is irreparable.

The Golden Hour

Golden Hour may be defined as the period during which all efforts are made to save a life before irreversible pathological changes can occur thereby reducing or preventing death in the second and third phase. This period may range from the time of injury to definitive treatment in a hospital.

Trauma care staging

Pre Hospital CareBasic Life SupportTriagePreparation at receiving hospitalHospital CareInitial assessment of the patientPrimary survey and ResuscitationA.T.L.SSecondary surveyHospital rehabilitation

Pre hospital

Rescue workers like doctors, ambulance crews, fire fighters, or any other trained person in BLS are the front runners for pre hospital care. They primarily handle airway, respiratory support, immobilisation of patient and control of external bleeding and shock which require urgent attention in saving a life. This group generally covers the “Platinum 10 Minutes”.

Pre hospital

The first 10 Platinum Minutes become important to make this golden hour effective and should be distributed as follows to make it fruitful.

Assessment of the victim and primary survey 1 minute

Resuscitation and stabilization 5 minutes Immobilization and transport to nearby

hospital 4 minutes

Basic Life Support

CPR is a emergency procedure that can be used to maintain some blood flow to the brain, heart, and other vital organs until trained medical personnel are available to provide more advanced treatment. It involves performing a series of chest compressions and rescue breathing after establishing a clear airway.

CPR

Position the person so you can check for signs of

life by laying the person flat on their back on a

firm surface and extending the neck.

II. Open the patient’s mouth and airway by lowering the head and

lifting the chin forward.

CPR

III. Determine whether the person is breathing by simultaneously looking for chest motion, listening for breath sounds, feeling for air motion on your cheek and ear.

CPR

IV. If the person is not breathing, pinch his or her nostrils closed, make a seal around the mouth and breathe into his or her mouth twice. Give one breath every five seconds - 12 breaths each minute - and completely refill your lungs after each breath.

CPR

V. If there are no signs of life - no response, movement or breathing - begin chest compressions. Place your hands over the lower part of the sternum, keep your elbows straight and position your shoulders directly above your hands to make the best use of your weight.

CPR

VI. Push down 1 1/2 to 2 inches at a rate of 80 to 100 times a minute. The pushing down and letting up phase of each cycle should be equal in duration. Don't jab down and relax. After 15 compressions, breathe into the person's mouth twice.

VII. After every four cycles of 15 compressions and two breaths, recheck for signs of life. Continue the rescue maneuvers as long as there are no signs of life.

Triage

Triage is the sorting of patients based on the level for treatment needed and the available resources to provide that treatment.

Triage is a very important decisive criteria when management of mass and multiple casualties is needed.

It basically aims on management of patients with greatest chance of survival first, with least expenditure of time, supplies, equipment and personnel.

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Organization of trauma services

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

triage decisions are crucial in determining individual patients survival

Preparation at receiving hospital

The trauma centre must be fully equipped and staffed resuscitation room, with comprehensive backup of all the necessary support teams such as radiology, blood bank, ICU, etc.

Basic trauma team should comprise of Specialist Anaesthetic, Cranio-Maxillofacial surgeon along with General, Orthopaedic , Neuro and Cardiothoracic surgeons plus paramedics and nurses.

The absolute minimum in a resuscitation room should be rubber latex gloves, plastic aprons and eye protection, considering any blood or body fluid to be HIV or HBsAg positive.

Initial assessment of the patient

Deaths following trauma follow a trimodal distribution.

The initial assessment generally defines 3 Peaks

Peaks of mortality

First peak

Occurs within seconds or minutes of the injury. death generally follows as a result of• Lacerations of the brain• Brain stem• High spinal cord• Heart, Aorta or any large blood vessels

Peaks of mortality

Second peakOccurs between a few minutes after injury to

about one hour later (golden hour)Deaths are generally due to• Severe chest injuries with Hemothorax• Cardiac tamponade• Abdominal trauma with a ruptured Spleen• Lacerations of the liver• Fractures particularly Pelvic or with other

multiple major bones.

Peaks of mortality

Third peak

Occurs some days or weeks after injury as a result of

• Multi organ failure• Respiratory distress• Sepsis

Primary Survey

Airway maintainance and Cervical spine control

Breathing and ventilation Circulation and Hemmorhage Control Disability- Neurological status Exposure and complete examination of patient

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Airway

Satisfactory airway signifies the implication of breathing and ventilation and cerebral and vital organ 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.

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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 injury

Obstruction of airway

asphyxia

Cerebral hypoxia

Brain damage/ death

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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 ( lateral position)

Removal of foreign bodies as a broken denture or avulsed teeth which can be inhaled and ensuring the patency of the mouth and oropharynx

Controlling the tongue position in case of symphysial 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

Continuous supervision

Additional methods in preservation of the airway in patient with severe facial injuries

Supplemental Oxygen via a well fitted mask OroPharyngeal Airway Naso-pharyngeal Airway

Supplemental oxygen given through a well fitted mask at 15 ltrs/min should be initially given to any trauma patient , to achieve maximum oxygenation of tissues.

Additional methods in preservation of the airway in patient with severe facial injuries

Oro-Pharyngeal Airway It is inserted upside down, until

soft palate is reached and then turned 180 degrees and slipped in place over the tongue.

It should be used with caution in an awake agitated patient.

As it may induce gagging, coughing, vomiting, all of which may raise the intra-cranial pressure.

Prevent not to push the tongue backwards while inserting the airway.

Additional methods in preservation of the airway in patient with severe facial injuries

Naso-Pharyngeal Airway• A well lubricated NPA is

gently introduced in an unobstructed nostril into the posterior oro-pharynx.

• It is generally better tolarated than a OPA in an awake patient as it avoids chances of coughing, gagging, vomiting and aspiration.

• It should not be used if any midface,FNOE or skull base fracture is suspected.

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Additional methods in preservation of the airway in patient with severe facial injuries

Definitive Airway This provides oxygen assisted ventilation via a cuffed tube present in a

trachea with the cuff inflated and the tube secured in place with a tape.Definitive airways are of three types1. Oro-Tracheal tubes2. Naso-tracheal tubes3. Surgical airway• Crico-thyroidotomy• Tracheostomy

Indications• Apnea• Inability to maintain a patent airway by other means• Potential compromise of airway following inhalational injury, facial

fractures, retro-pharyngeal hematoma• Sustained seizure activity• Closed head injury requiring assisted ventilation (GCS <8 )

Additional methods in preservation of the airway in patient with severe facial injuries

Endotracheal intubation Check cervical spine before

intubation The tongue is displaced to

the left side by the Laryngoscope, which is then slowly advanced till the epiglottis comes to view.

The tube is then advanced into the trachea.

Additional methods in preservation of the airway in patient with severe facial injuries

Tracheostomy Surgical establishment of an

opening into the trachea Indications: 1. when prolonged artificial

ventilation is necessary2. 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

Tracheostomy

Cricothyroidotomy

Cervical spine injury

• All patients with maxillofacial trauma carry a high index of suspicion for cervical spine injuries.

• Can be deadly if it involves the odontoid process of the axis bone of the axis vertebra

• In all patients with major supra clavicular injury, cervical collar should be placed to minimize the risk of any deterioration. Commercially available long spine boards and head blocs can be used. If not available in emergency, then sand bags can be placed bilaterally and taped firmly with head and chin.

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Cervical spine immobilisation

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Breathing and ventilation

Chest injuries:• Tension pneumothorax• Open pneumothorax• Flail chest• Massive haemothorax• Cardiac tamponade

Clinical features• Deviated trachea• Absence of breath sound• Dullness to percussion• Paradoxical movements• Hyper-response with a large pneumothorax• Muffled heart sounds

Radiological features• Loss of lung marking• Deviation of trachea• Raised hemi-diaphragm• Fluid levels• Fracture of ribs

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Emergency treatment in case of chest injury

Tension pneumothorax• Needle thoracocentesis with large 12-14 G needle in 2nd intercostal space• Insertion of chest drain into 5th intercostal space

Open pnemothorax• Promptly closing the opening with sterile dressing and tapes• Insertion of Chest drain into 5th intercostal space

Flail chest• Endotreacheal intubation for unstable flail chest• Intermittent positive pressure ventilation• Re-expand lung

Cardiac Tamponade• pericardiocentesis• Needle decompression of the pericardium• Decompression of gastric dilation and aspiration of stomach content

Open Pneumothorax

Flail Chest

Flail Chest

Cardiac Tamponade

Massive Haemo thorax

Massive Haemothorax

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Circulation

Shock is defined as an abnormality of the circulation that results in inadequate organ perfusion and tissue oxygenation.

Haemmorhage is an acute loss of circulating blood volume

Patient resuscitationRestoration of cardio-respiratory function

Shock managementReplacement of lost fluid

Recognition of shock

Central pulse (carotid/femoral)-• Normal-full,slow and regular• thready pulse indicative of hypovolemia.Skin colour• Normal-pinkish• Ashen gray skin of face and pale-whitened in extremities

depicts hypovolemia.• Level of conciousness is low with confussion, agression,

drowsiness and coma.• Tachypnea due to hypoxia and acidosis• Generalised weakness.• Low urinary output.

Haemorrhage

Class I• Less than15% blood loss• Equivalent to a unit of blood donation.• No tachycardia, no P/BP/Resp changes• Blood volume restored in 24 hrs.

Class II• 15-30% or 750-1500 ml blood loss.• Tachycardia, tachypnea, low pulse pressure• Urinary output mildly less.• No blood transfusion but crystalloids are needed.

Haemorrhage

Class III• 30-40% or >2000 ml blood loss• Marked tachycardia, tachypnea• Significant fall in systolic BP• Always requires blood transfusion

Class IV >40% blood loss Immediately life threatning Requires urgent rapid transfusion and surgical intervention Marked tachycardia, tachypnea Significant fall in systolic BP Mental status markedly depressed Urinary output negligible

Fluid resuscitation

☞Adequate venous access at two points, prefarably ante-cubital veins or in emergency femoral or sub-clavian veins.

☞ Hypotension assumed to be due to hypovolaemia

☞ Resuscitation fluid can be crystalloid, colloid or blood2 ltrs of warmed crystalline prefarably Ringers Lactate. Then

patient re-assessed to be a Responder, Transient responder or a Non responder.

☞ Surgical shock requires blood transfusion, preferably with cross matching or group O. Rh –ve for females of child bearing age to prevent sensitisation and future complications.

☞ Urine output must be monitored as an indicator of cardiac out put

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Maxillofacial haemorrhage

Usually not life threatning. Mostlt due to cut Facial or Superficial Temporal arteries. Facial-to be compressed against mandible body anterior

to masseter. Superficial temporal to be compresed against cranium

anterior to the ear. Also closed bleeding from midface # and FNOE complex

may be complex to define the exact source of bleeding. Do trans nasal packing with adrenalin soaked ribbon

gauze.

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Disability -Neurological evaluation

Rapid assessment of neurological disability is made by noting the patient response on four points scale:

A alert

V Responds to verbal stimuli

P Responds to painful stimuli

U unresponsive to all stimulus

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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

Adjuncts to primary survey

ECG EEG CXR Cervical spine- AP & Lateral USG Diagnostic Peritoneal Lavage Lab Reports CT MRI

SECONDARY SURVEY

Head to toe and front to back evaluation. History A- Allergies M- Medications currently used. P- Past illness/ Pregnancy L-last meal E- Events/environment related to the injury

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Glasgow coma scale (GCS)(Teasdale and Jennett, 1974)

Eye opening

Motor response

Verbal response

Spontaneous 4 Move to command

6 orientated 5

To speech 3 Localizes to pain

5 Confused 4

To pain 2 Withdraw from pain

4 Inappropriate words

3

none 1 flexes 3 Incomprehensible sounds

2Extends 2 none 1none 1

Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15

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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

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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

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

Head injury

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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

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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)

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

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Pelvic trauma

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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

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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

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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

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•

maintain complete sterile environmentwhenever there is dirt or debris in the wound, do tetenus toxoid prophylaxis. (1ml I.M)

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 )

Prevention of infection

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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

Necessary medications

Diet (fluid, semi-fluid and solid food) intake and output (fluid balance chart)

Hygiene and physiotherapy

Proper timing for surgical intervention

References

Maxillofacial Trauma & Esthetic Facial Reconstruction – Peter Ward Booth

Oral & Maxillofacial Surgery Volume 3 Trauma- Fonseca

Oral & Maxillofacial Surgery- Neelima Malik Oral & Maxillofacial Surgery- S.M.Balaji Internal Medicine- Harrisons The Times of India, article August 17, 2009 Internet source

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