*Maxillofacial traumaManagement of traumatized patient

*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 countriesBeek and Merkx 1999

Sport and athletic injuries

Industrial accidents

Domestic injuries and falls

*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%)

*Factors affecting the high/low incidence of maxillofacial traumaGeography 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 al 1998)

*Assessment of traumatized patientThis should not concentrate on the most obvious injury but involve a rapid survey of the vital function to allow management priorities5% of all deaths world wide are caused by traumaThis might be much higher in this country

*Peaks of mortalityFirst 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 of multi-organ failure

*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 triagetriage decisions are crucial in determining individual patients survival

*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

*AirwaySatisfactory 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

*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 forwardSequel of facial injuryObstruction of airwayasphyxiaCerebral hypoxiaBrain damage/ death

*Immediate treatment of airway obstruction in facial injured patientClearing 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

*Additional methods in preservation of the airway in patient with severe facial injuriesEndotracheal 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

*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

*Breathing and ventilationChest injuries: Pneumothorax, haemopneumothorax, flail segments, reputure daiphram, cardiac tamponadesignsClinical Deviated tracheaAbsence of breath soundsDullness to percussionParadoxical movementsHyper-response with a large pneumothoraxMuffled heart soundsRadiographicalLoss of lung markingDeviation of tracheaRaised hemi-diaphragmFluid levelsFracture of ribs

*Emergency treatment in case of chest injuryOccluding 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

*Circulation Circulatory collapse leads to low blood pressure, increasing pulse rate and diminished capillary filling at the periphery

Patient resuscitationRestoration of cardio-respiratory function

Shock managementReplacement of lost fluid

*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

*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

*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

*Glasgow coma scale (GCS)(Teasdale and Jennett, 1974)Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15

Eye openingMotor responseVerbal responseSpontaneous4Move to command6Converse5To speech3Localizes to pain5Confused4To pain2Withdraw from pain4Gibberish3none1flexes3grunts2Extends2none1none1

*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 diagnosisMaintenance of a stable stateDetermination of priorities in treatmentAppropriate specialist referral

*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 traumaHead injuryAbdominal injuryInjury to extremities

*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

*Signs and symptoms of head injuryLoss of conscious ORHistory of loss of consciousHistory of vomitingChange 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 fractureSkull base fracture (battles sign)Temporal/ frontal bone fractureNaso-orbital ethmoidal fracture

*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

*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, urineEmergency laprotomy

*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 injuryImpaired distal perfusion (risk of ischemia)Compartment syndrome (limb loss)Traumatic amputation

*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

*Preliminary treatment in complex facial injurySoft 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 damageReduction in visual acuityEyelid injury

*Prevention of infectionFractures 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 scanManagement:Dressing of external woundsClosure of open woundsReposition and immobilization of the fracturesRepair of the dura matterAntibacterial prophylaxis (as part of the general management (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

*In patient careNecessary medications

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

Hygiene and physiotherapy

Proper timing for surgical intervention