PRELIMINARY CARE IN

MAXILLOFACIAL INJURIES

Presented by -

Dr. SHEETAL

KAPSE

Moderator -

Dr. RAJASEKHAR

G.

INCLUSIONS

Introduction

Aim of trauma care

Pre hospital care

Triage

Initial assessment of the patient

Primary survey and resuscitation

ABCDE

BLS

Basic airway maneuvers

Advanced airway maneuvers

Surgical airway

Breathing and ventilation

Circulation and haemorrhage

Recognition of shock and management

Maxillofacial aspects

Exposure and environmental control

Primary survey

Secondary survey

Physical examination

Conclusion

References

Maxillofacial trauma- injury facial soft tissue or its

bony structure.

Commonly associated with multiple system

injuries.

Most common mechanisms of injury -blunt or

crush injuries caused by RTA or assault.

These injuries include cranial, spinal, Upper

and lower body injuries.

3

INTRODUCTION

• Leading cause of death from

birth to 44 yrs of age

1st

cancer

2nd

atherosclerosis

3rd

trauma

Identification of major trauma pts at the scene of the incident

Immediate intervention for safe transport

Rapid transfer to trauma centre for surgical management and critical care

Coordinated specialist reconstruction

Targeted comprehensive rehabilitation

AIM FOR TRAUMA MANAGEMENT

Trauma care continuum

Arrival of emergency

services

Transfer to hosp RR

RR management

Definitive care

Discharge

Long-term support

services

TraumaRR = resuscitation room

To identify & deliver pt to a place of a definitive care

safely & quickly

Ambulances are well equipped

Air ambulance facilities

Ambulance crew- paramedics

PRE HOSPITAL CARE

Triage is the sorting of patients based on their need

for treatment and the available resources to provide

the treatment

Starts at the accident scene itself

2 types

- Multiple casualties

- Mass casualties

TRIAGE

When the number of patients and the severity of

their

injuries do not exceed the ability of the facility to

provide

care.The situation in which the number of patients

and the severity of their injuries exceed the

capability of the facility and the staff.

If the number of trauma victims

exceeds the ability of the hospital to

handle them, a major incident is called,

and a pre-prepared and practiced

action plan is implemented whereby

neighbouring hospitals are alerted and

warned that they will also be receiving

patients.

PREPARATION AT THE RECIEVING HOSPITAL

All members should have

appropriate training, such as the

Advanced Trauma Life Support

(ATLS) course, which has become

the gold standard and common

language of trauma management.

Rescuer safety measures should be

followed.

Deaths from trauma follow a trimodal distribution

1. 1st peak, 40% - 50% trauma deaths, immediately or within minutes of

the accident, due to lacerations of the brain, brainstem, high spinal cord,

heart, aorta, or other large blood vessels.

2. 2nd peak , 30 % trauma related death ( mins – hour), due to hypoxia and

hypovolemic shock as a result of severe chest injuries with hemothorax or

cardiac tamponade, abdominal trauma with ruptured spleen or liver, or

orthopaedic injuries such as fractured pelvis or long bones associated

with significant blood loss. - GOLDEN HOUR

INITIAL ASSESSMENT OF THE PATIENT

Maxillofacial trauma & esthetic facial reconstruction peter ward

booth , 11th ed

3. 3rd peak – multiple organ failure, sepsis or distress

Maxillofacial trauma &

esthetic facial reconstruction

peter ward booth , 11th

edition

INITIAL ASSESSMENT

BLS

Basic Life Support

General considerations

Adult chain of survival

Pediatric chain of survival

Step 1: Scene Safety and

Assessment

Step 2: Activation of

emergency response system

and AED

BLS/CPR for adults

Step 3: Pulse check

Step 4: CPR

chest compression

technique

Step 4: CPR

opening the airway for breaths : head tilt chin lift

Jaw thrust technique

2 rescuer technique

AED for adults and children > 8 years

1. Power on

2. Attach

3. Clear & Analyze

4. Shock if advisable

5. Immediately resume CPR

6. Reanalyze after 2 min (5 cycles of CPR)

BLS/CPR for children 1 year to puberty

BLS/CPR for infants

• Compression rate and ratio for lone rescuer

• Compression rate and ratio for two rescuer

• Compression depth

• Compression technique

• When to activate the emergency response

system

BLS/CPR for children 1 year to

puberty

• Location of pulse check

• Compression rate and ratio for lone rescuer

• Compression rate and ratio for two rescuer

• Compression depth

• Compression technique

• When to activate the emergency response

system

AED for infants and children from 1-8

years

Mouth to mouth breaths

Rescue breathing

Pulse Breaths

Rescue breathing for adultsRescue breathing for infants

& children

Give 1 breaths every 5-6 sec

(about 10-12 breaths/min)

Give 1 breaths every 3-5 sec

(about 12-20 breaths/min)

Give each breath in 1 sec

Each breath should result in visible chest raise

Check the pulse every 2 min

Mechanisms of Injury

and

Suspected

Injury Patterns

SEQUENCE OF

MANAGEMMENTTrauma (Road traffic accident fall etc.)

↓

Primary Survey -> ABCDE defines

the specific prioritized evaluations and intervention that should be followed in all injured patients

↓

Secondary Survey

After initial survey has been accomplished and the patient has been stabilized

Involves more time – consuming tests and observations

Does not begin until primary survey is completed

9

A B C D E

A: Airway with cervical spine control

B: Breathing and Ventilation

C:circulation and haemorrhage control

D:Disability – (neurological status)

E: Exposure + environment – completely undress

the patient

F: Frequent Reassessment must be made

A: Airway with Cervical Spine

Control

High index of suspicion for cervical

spine injury in maxillofacial traumas

and multisystem trauma

15% of supraclavicular injury pt

5 % of head injury pt

spinal injuries most commonly

occur in the cervical region

Cervical spine assessment

Basic Airway Maneuvers

Supplemental oxygen

Look, Listen,and Feel.

jaw thrust

chin lift

Oro/ nasopharyngeal

airway

nasopharyngeal airway

Supplemental oxygen

Supplemental oxygen delivered through a well-

fitted reservoir (rebreathing) mask, at a rate of 15

L/min

LOOK LISTEN FEEL

JAW THRUST AND CHIN LIFT

Maxillofacial Injuries

• Up to 5% of patients presenting to

the emergency department have

facial injuries, and some may have

airway compromise.

• Maxillofacial trauma demands

aggressive airway management, and

it may be appropriate for the

maxillofacial surgeon to assist the

anesthetist in assessing and

securing the airway

Advanced Airway Maneuvers:

Definitive Airway

The orotracheal tube, the nasotracheal tube, and the

surgical airway

A definitive airway should be considered if any of the following is present:

• Apnoea

• Inability to maintain a patent airway by other means

• The need to protect the lower airway from blood or vomit

• Potential compromise of the airway (e.g., after burn injury, other inhalational injury,

facial fractures, retropharyngeal hematoma, or sustained seizure activity)

• A closed-head injury requiring assisted ventilation (Glasgow Coma Scale [GCS] score

of 8 or less)

• Inability to maintain adequate oxygenation by facemask oxygen supplementation

Orotracheal Intubation

A size 8 tube is

usually suitable

for women and

a size 9 tube for

men

Nasotracheal Intubation

Surgical Airway

Inability to intubate the trachea orally or nasally is a clear indication for creation of a

surgical airway

tracheostomyNeedle

cricothyroidotomy

A, Assemble the required equipment: alcohol wipe, 12- to

14-gauge intravenous cannula with 10-mL syringe with 1 mL

of air, and intravenous tubing with Luer lock connection to

cannula and Y-connector.

B, Insert cannula through the cricothyroid membrane,

45 degrees caudad; eject air from syringe and aspirate. Air

indicates correct placement.

C, Remove syringe and needle while fully inserting the

cannula. Connect tubing to cannula. Connect the other end to

the oxygen supply and run at 12 to 15 L/min, using

intermittent insufflation (1 second of occlusion of the Y-

connector and 4 seconds off).

Technique of needle cricothyroidotomy

Technique of surgical

cricothyroidotomy

A, Assemble the required equipment:

local anesthetic with lidocaine

(lignocaine) and epinephrine

(adrenaline) for both anesthesia and

vasoconstriction.

B, Secure in-line immobilization of the

patient’s head by an assistant. Make a

3-cm horizontal incision through skin

over cricothyroid membrane (having first

removed the cannula if needle

cricothyroidotomy was performed).

C, Stab vertically down through

membrane and make a

1-cm incision.

D, Insert tracheal dilator horizontally

and open it, separating the thyroid and

cricoid cartilages. Suck out the

trachea with a Yankeur-type sucker.

E, Having checked that the cuff inflates,

insert the tracheostomy tube into the

trachea.

F, Remove the introducer, inflate the

cuff, and connect oxygen supply via

Ambu bag. Reassess and monitor O2

ALGORITHM TO SURGICAL AIRWAY

BREATHING & VENTILATION

Once the airway has been secured, breathing and

ventilation must be assessed.

THORACIC INJURIES

A: Airway obstruction

T: Tension pneumothorax

O: Open pneumothorax

M: Massive haemothorax

F: Flail chest

C: CIRCULATION AND

HAEMORRHAGE CONTROL

• Acute blood loss resulting in hypovolemic shock is responsible for 30% to

40% of trauma deaths.

• 50% in prehospital period

• Acute blood loss is one of the major causes of preventable deaths on arrival

at hospital.

ECA LIGATION Facial artery ligation

SHOCK

Metabolic acidosis

Hypothermia

Hypocoagulopathy

Recognition of shock

Tachycardia

Skin colour

Level of consciousness

Respiratory rate

Urine output

AMERICAN COLLEGE OF SURGEONS (2001),

Classification of acute hemorrhage

Committee on Trauma. Advanced Trauma Life Support Student

manual. 6th ed. Chicago. American College of Surgeons. 2001: 87-107.

Initial management of haemorrhagic shock

External

bleeding

Occult bleeding

The twin goals in resuscitation of the shock patient are prevention

of further blood loss and the earliest restoration of tissue perfusion

Posterior nasal pack

Packing using foley’s

FLUID REPLACEMENT

In a shocked, hypotensive patient, the aim of fluid resuscitation should be to

restore critical organ perfusion until hemorrhage that is amenable to surgery is

stemmed.

• Responders

• Lost < 20% blood vol

• Respond well & return to

normalcy

• Transient Responders

• Vitals initially improve but

then deteriorate

• They are actively bleeding

from open or occult site

• Non Responders

• vitals don't improve

• Rate of blood loss = fluid being

replaced

• Central venous line should be

established

Goal : the oxygen carrying capacity of blood.

Indications

1. Hb <6 gm% (normal =10 gm%)

2. age

3. Medical status

4. Major surgical procedure

5. Anticipation of ongoin blood loss >100ml/min

6. Acute blood loss > 40% (2L crystalloid 3:1 ---

colloid 1:1 )

D : Disability

A rapid evaluation is performed at the end of the

primary survey, and this establishes the patient’s

level of consciousness.

A: Alert

V: responds to Vocal stimuli

P: responds to Painful

stimuli

U: Unresponsive to all

stimuli

E: EXPOSURE &

ENVIRONMENTAL CONTROL

SECONDARY SURVEY

It aims to identify and fully appreciate all other injuries that the

polytraumatized patient may have suffered that might otherwise go

unnoticed, particularly in the presence of a reduced GCS score.

History

Physical examination

SCALP

EYES

MAXILLOFACIAL

STRUCTURES

NECK AND CERVICAL SPINE

CHEST

ABDOMEN

PERINEUM, RECTUM , VAGINA

MUSCULOSKELETAL

ASSESSMENT

SPINAL CORD ASSESSMENT

Eyes

1. Direct injury to the globe (blunt or

penetrating injury)

2. Direct injury to the optic nerve (due to crush

or transection via bony injury at the orbital

apex)

3. Indirect injury to the optic nerve (from

deceleration or shearing force)

4. Critical reduction in tissue perfusion, either

generalized or local (systemic hypotension or

orbital compartment syndrome)

Maxillofacial Structures

• Examine the nose for deformity, pain, mobility, and difficulty in breathing,

which suggest bony or cartilaginous fractures.

• Epistaxis and, in particular, CSF rhinorrhoea suggests an anterior cranial

fossa fracture at the cranial base, the ears for hemotympanum and CSF

otorrhea.

• Bleeding from the external auditory canal soft tissue wall may be

secondary to mandibular condylar fracture with or without glenoid fossa

injury

• Lastly, examination of the mouth is performed. Buccal vestibule(zygoma),

the palate (maxilla), and the floor of the mouth(anterior mandible) is noted

CONCLUSION

As maxillofacial surgeons we are trained to

attend head and neck emergency situations in

the casualty. One should have thorough

knowledge about various protocols to manage a

trauma patient. And should attend BLS & ATLS

courses at regular intervals.

REFERENCES

Peter Ward Booth, Barry L. Eppley, Rainer Schmelzeisen. Maxillofacial Trauma and Esthetic Facial

Reconstruction. Churchill Livingstone, 2003 , 11th edition.

Oral and Maxillofacial Trauma, Volume 2. Raymond J. Fonseca,Robert V. Walker Snippet view - 1991 .

WILLIAMS, J. L., & ROWE, N. L. (1994). Rowe and Williams' maxillofacial injuries. Edinburgh, Churchill Livingstone.

Williams NS, Bullstrode CJ, O’connell PR. Bailey & Love’s short practice of surgery, 25th edn. Annals of the royal college of surgeons of england. 2010;92(2):178. Doi:10.1308/003588410x12628812459094.

Resuscitative strategies in traumatic hemorrhagic shock , bouglé et al. Annals of intensive care 2013, 3:1

Committee on trauma. Advanced trauma life support student manual. 6th ed. Chicago. American college of surgeons. 2001: 87-107.