Maxillofacial trauma

Management of traumatized patient

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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
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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 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 4 ice in midwinter) of RTA, violence and sporting injuries (Hill et al 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

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

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

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
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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

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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 (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
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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. 3. 4. 5.

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
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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

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Chest injuries:

Breathing and ventilation

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
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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
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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

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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
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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

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

Response appropriately, is Aware

V
P U

Response to verbal stimuli

Response to painful stimuli Does not responds, Unconscious
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Glasgow coma scale (GCS)

(Teasdale and Jennett, 1974)

Eye opening
To speech To pain none

Motor response
3 Localizes to pain 2 Withdraw from pain 1 flexes Extends none

Verbal response
6 Converse 5 Confused 4 Gibberish 3 grunts 2 1 none 5 4 3 2 1

Spontaneous 4 Move to command

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

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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

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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 (battles sign) Temporal/ frontal bone fracture Naso-orbital ethmoidal fracture

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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 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
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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)

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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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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 patients 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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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 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

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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