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PRIMARY CARE FOR TRAUMA
Presented byPresented by : Dr Mohammed Haneef
Contents
Introduction
Principals of management
Sequence of management
Primary Survey
Secondary Survey
Conclusion
2
Introduction
Maxillofacial trauma involves injury to the facial soft
tissue or its bony structure.
It is commonly associ...
 Trauma is the leading cause of
death in children and young
adults. Its effects are protean,
affecting not only the victi...
The first priority in management of a
patient with trauma is obviously the
preservation of the life of the patient.
6
TWO OBJECTIVES OF MANAGEMENT
To save life
To restore function
7
Principles of Management (Triage System)
When a patient with severe traumatic injury is first seen, an
immediate general e...
SEQUENCE OF MANAGEMMENT
Trauma (Road traffic accident fall etc.)
↓
Primary Survey -> ABCDE defines
the specific prioritize...
Primary survey
For assesment of patients in systemic fashon
Establishment of treatment priorities based
on injuries, vit...
PRIMARY SURVEY
A-Airway management with cervical spine stabilization
B-Breathing and ventilation
C-Circulation with hae...
“A” AIRWAY PATENCY MANAGEMENT
Maintenance of patency of airway must be given
priority consideration, since adequate oxygen...
Clinical Signs & Symptoms of Respiratory
Distress (Obstructions)
Initially there will be restlessness, apprehension,
anxi...
Crowing sound, strider, intercostals retraction.
Suprasternal indrawing of the tissues or
supraclavicular retraction
De...
Causes of respiratory obstructions related to
maxillofacial injuries.
 Inhalation of blood clot, vomit, saliva, thick muc...
16
Systematic approach to airway
management
1. Initial assessment : Recognize airway obstruction
2. Perform airway maneuve...
Airway Management
Non –Surgical
 Positioning of the patient
 Oropharyngeal toilet
 Suctioning of Vomitus
 Anterior tra...
Non Surgical Treatment
1.Position of the Patient.
Semi-prone position- will maintain clear airway mainly by
allowin& CSF ...
 Supine position with head extended should be
deprecated especially in spinal injuries.
18
2. Oropharyngeal Toilet
 All blood clot, saliva, thick mucus or foreign bodies etc.
should be cleared from the oral cavit...
3. Suction
If suction machine is available, then catheters should be
used to clear the nose, oral cavity and throat.
20
4. Anterior Traction of the
Tongue
 Control the tongue by the proper positioning
of the patient; or the tongue can be pul...
5. Immediate restoration of the position of
soft palate.
- It can be brought about by doing disimpaction of the maxillary
...
6. Mouth to mouth breathing
 First ventilation cycle is comprised of
four quick, full ventilations of the
victim without ...
 Exhalation is a passive process.
- The rescuer removes his or her mouth from
that of the victim, takes in a breath of fr...
Rescuer places fingers of one hand on bony anterior portion of
mandible;other hand is placed on forehead and rotates the
h...
7. Endotracheal intubation
If the airway is compromised or its integrity is
deteriorating as a result of haematoma formati...
Criteria for intubation
Clinical
 Shortened speech
 Use of accessory muscles
 Subjective air hunger
 Change in mental ...
INDICATION FOR TRACHEAL
INTUBATION(ATLS)
Need for airway protection
 Unconscious
 Severe maxillofacial fractures
 Risk ...
 In addition, two more indications are
A combative patient who exacerbate potential
injuries & who cannot safely be cont...
Contraindication
 Real contraindication to tracheal intubation is the
ability to adequately secure & maintain an airway b...
 Fiberoptic techniques are generaly not successful if
there are notable airway secretions, bleeding , or
emesis.
 Apnea ...
Orotracheal intubation
 Preparation
 Suction
 Airway.
 Laryngoscope.
 Tube.
 Equipments
33
34
Airway management devices:
A - oropharyngeal (Guedel) airway;
B - nasopharyngeal airway;
C - endotracheal tube with inf...
Letter A shows the wrong and letter B shows the
correct position of patient's head
35
Position of the patient
36
Technique of direct laryngoscopy
and orotracheal intubation.
Curved blade placement in
orotracheal intubation.
Technique
Straight blade technique:
37
38
Fiberoptic intubation Indications:
 Routine intubation, difficult
intubation, abnormal airway,
compromised airway
 N...
39
Surgical airway
Inability to intubate the trachea for any reason is
an indication for creation of a surgical airway
wh...
SURGICAL
Tracheostomy
 In greek it means creating a window in the anterior
wall of the trachea.
 Tracheotomy: an incisio...
INDICATIONSMajor laryngeal trauma with concern that cricothyrotomy or
orotracheal intubation might result in retraction o...
Contraindication
 if the patient airway can be safely secured by other
means( rescue airway, RSI, needle or open
cricothy...
Complications
Perioperative
Hemorrhage
Pneumothorax
Subcutaneous
emphysema
Esophageal injury
False passage
Aspirati...
Procedure
44
45
46 46
47 47
C spine immobilisation
 Well fitting hard collar & backboards
 “sandbags”
48
49
Cricothyrotomy
1.Needel cricothyrotomy
2. cricothyrotomy
50
Indications
1. Maxillofacial trauma; obstruction of the airway from
massive facial trauma is the most common indication...
Contraindications
1. Age: in children below age 11.
2. Crush injury to larynx: result in laryngeal
separation
3. Preexisti...
 Needle cricothyrotomy procedure.
(A) Positioning (assuming no
contraindications) to expose the
external anatomy (eg, lar...
Cricothyrotomy
 Palate thyroid cartilage-inferior to the mandible & hyoid
bone in the midline
 Cricoid cartilage – 2 to ...
54
Complications
Perioperative
Improper tube placement
Hemorrage
Prolonged execution time
Pneumomediastinum
Subcutaneous...
ADVANTAGES OF CRICOTHYROTOMY
OVER TRACHEOSTOMY
 Faster than tracheostomy, generally less than
2 min.
 Easier to perform,...
B: Breathing
 Once the patient airway has been established & the
breathing sustained, the patient should be placed on
sup...
C:circulation
1. Hypovolemic shock
2. Control of bleeding
3. Fluid resuscitation
4. Blood product replacement.
58
Hypovolemic shock and
hemorrage
 Hemorrage is the most common cause of hypovolemia in the
multisystem injured patient.
 ...
Classes of hemorrhage
CLASS I CLASS II CLASS III CLASS IV
Blood volume
loss
Up to 15% 15% to 30% 30-40% >40%
Adult blood
v...
 While the primary assessment is taking place, ATLS
dictates that a minimum of two large-bore(16 to 14 gauge)
intravenous...
 In hypovolemic shock, a standard volume resuscitation
approach is to administer 2 liters of crystalloid fluid as
a bolus...
Blood product replacement
 Blood transfusion is to increase the oxygen-carrying
capacity of the blood
 Indicated for hem...
 If the patient doesn't respond to initial fluid
resuscitation and/or blood transfusions,
measure CVP with a catheter or ...
Control of bleeding
 Prompt control of post traumatic bleeding is a must.
 Initial digital compression should be given t...
 Deep wounds also can be packed with gauze
till definite measures are taken.
 Nasal bleeding can be stopped by using
rib...
Method of insertion of a postnasal
pack  A flexible aspiration catheter 3mm in
diameter is passed via one nasal
aperture ...
Neurologic Examination(Disability)
 A brief neurological evaluation is performed to
establish
The patient’s level of con...
The committee on trauma of the American
college of surgeons recommends AVPU
system
 A rapid assessment of neurological di...
EXPOSURE
Patient should be completely disrobed so that all the
body can be visualized, palpated, and examined for
injurie...
Conclusion
 In the care of the patient with maxillofacial injuries, it is essential that
the surgeon have the knowledge a...
References
1. Miller’s Anaesthesia. Vol. I
2. Oral and Maxillofacial trauma. 2nd edition. eds
RJ Fonseca and RV Walker. 19...
Head Injuries
 C – consciousness
 R – respiration
 A - Trauma
 N – Neck
 Cervical/Carotid Injury
 E- Eyes
 Pupils
...
HEAD INJURIES
These may include injuries of the scalp, skull, brain, and
blood vessels.
Scalp Injuries
1. Laceration of...
Physical Examination
 1. Assess level of consciousness. Use the Glasgow Coma Scale. The minimum
score is 3 and the maximu...
Brain Injuries
 1. Concussion: No gross pathology. Transient loss of
consciousness. CT scan is normal.
 2. Contusion: Br...
Brain damage is classified into:
1. Primary brain damage. It occurs at the time of injury
and is irreversible (i.e. lace...
Intracranial Bleeding
 1. Epidural hematoma: Usually due to laceration of the middle
meningial artery or venous sinuses. ...
 3. Intracerebral hematoma: Usually beneath a cortical contusion.
 4. Subarachnoid hemorrhage: It often gives symptoms a...
Ocular function
 Reaction of pupils to light
 Extraocular muscle function
 Oculovestibular and oculocephalic reflexes
...
Cranial nerve examination
 Olfactory nerve
 Optic nerve
 Occlumotar
 Trochlear
 Abducent
 Trigeminal nerve
 Facial ...
Upper motor lesion Vs lower Motor lesion
 Mucle groups
 Rigid
 Slight wastine
 Flexor spams
 Brisks jerks
 Plantars ...
Motor nerve examination
 Grade 0 – no motor activity
 Grade 1 – papable muscle contraction
 Grade 2 – complete range of...
Sensory system
 Grade 0 – absent
 Grade 1 – present
 Grade 2 – normal
 Grade 3 – normal active
 Grade 4 – hyperactive...
Diagnostic tests
 1. Plain skull x-rays only if CT scan is not available (may show fractures, foreign
bodies, air in the ...
Management of Scalp injuries
 Scalp lacertations:Copius irrigation to cleanse the wound,
carefull debridement. Closure in...
Managemet of Mild Head injury
GCS 14 - 15
• History
• Name/Age/Sex
• Mechanism of Injur
• +/- loss of consciousnes
• Level...
Management of Moderate head Injury (Flow Chart)
GCS 9-13
Admission
CT Scan of Brain
If patient improves discharge if patie...
Management in Case of Sever head injury
GCS score 3-8
• ABC
• Previous history for allergies,
medications, past illness, l...
Skull fractures
 Skull fracture predispose a conscious to about 400
times the possibility of cranial haematoma and about
...
Management
 Closed non depressed fractures:- observation and monitoring
and medical line of treatment for associated intr...
Basal skull fractures
 Associated tear of the dura and arachnoid at the base of the skull/
middle or anterior cranial fos...
C/F
 Headache
 Decreased hearing
 Salty taste in mouth
 Pneumocephalus present in 30% of the patients
Diagnosis
Bed si...
Management
 There may be presence of meningitis - Prophylactic
antimicrobials (3rd
generation cephalosporins)
 Head elev...
Cervical Spine Injuries
 Only 2% incidence of cervical spine injuries in maxillofacial
trauma patients
 Identification o...
Orbital injuries
 Opthalmic exatmination:
Visual accuity
Enoptholmoses/proptosis/diplopia
 Eye movement
Size , level ...
100
Hutchinson’spupil
•Seen in case of cerebral compression
•Consists of 3 stages
Pupil of the side of injury
contract
due...
101
Pupillary response inference
Bilaterally reactive pupils that react to
both direct & consensual stimuli
Normal pupil
B...
102
Cranial nerve 3,4,6:
- light reflex
- intorsion and extorsion
Vision-threatening injuries (VTI)
 These include:
 Retrobulbar haemorrhage;
 Traumatic optic neuropathy;
 Open and Clo...
Retrobulbar haemorrhage
 A tense, proptosed globe and a dilated pupil may be the only
clues to the presence of a retrobul...
CHEST INJURIES
Rib trauma is occurs in aout 56% of poly trauma patients followed by pneumothorax,
flail chest, injuty to h...
PNEUMOTHORAX
Definition: The presence of free air in the pleural cavity.
Symptoms and signs
1. Often asymptomatic.
2. ...
 HEMOTHORAX
Definition: Free blood in the pleural cavity.
Symptoms and signs
1. Often asymptomatic.
2. Dyspnea, tachyp...
TENSION PNEUMOTHORAX
Definition: Air under pressure in the pleural cavity due
to a valve effect. Associated with life-thr...
Flail Chest
 Occur as a result of three or more contigous ribs fracturedd at two
points
 Lateral type of flail chest is ...
Placement of thoracic tube
Abdominal Injuries
The abdomen is systemically examined by inspection,
palpation and auscullation and percussion
Injury ...
DPL (diagnostic peritonial Lavage)
 Indicated in patients with + H/O abdominal trauma with
abdominal pain /tenderness.
 ...
Managemet of abdominal injuries
 Physical examination to be repeated every 6 hourly
 Management of shock, sepsis
 Surgi...
Urological injuries
 Occurs in 10% polytrauma patients
 Majority of injuries are non threatning
 Evaluation of kidneys,...
Skeletal injuries
Retrograde intubation
Submental intubation
Primary care in trauma
Primary care in trauma
Primary care in trauma
Primary care in trauma
Primary care in trauma
Primary care in trauma
Primary care in trauma
Primary care in trauma
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  1. 1. PRIMARY CARE FOR TRAUMA Presented byPresented by : Dr Mohammed Haneef
  2. 2. Contents Introduction Principals of management Sequence of management Primary Survey Secondary Survey Conclusion 2
  3. 3. Introduction Maxillofacial trauma involves injury to the facial soft tissue or its bony structure. It is commonly associated with multiple system injuries.  The most common mechanisms of injury are blunt or crush injuries caused by personal assault and motor vehicle accidents . These concomitant injuries include cranial, spinal upper and lower body injuries 3
  4. 4.  Trauma is the leading cause of death in children and young adults. Its effects are protean, affecting not only the victim but also their relatives and society as a whole.  If basic principles of primary care are applied immediately, the contribution can benefit the patient and enhance his chances of survival. 4
  5. 5. The first priority in management of a patient with trauma is obviously the preservation of the life of the patient. 6
  6. 6. TWO OBJECTIVES OF MANAGEMENT To save life To restore function 7
  7. 7. Principles of Management (Triage System) When a patient with severe traumatic injury is first seen, an immediate general evaluation must be made to determine if emergency treatment is necessary. Treatment Priorities I. Immediate Intervention (5% main category for reported deaths) - Maintainance of airway Required - Poly Trauma Patients - Cardiac Conditions like arrest - Management of Shock and Bleeding II. Treatment required urgently ( 10-15%) - Intra – abdominal bleeding - Head injuries - Chest injuries III. Treatment that can wait ( non urgent -80%) Maxillofacial trauma 8
  8. 8. SEQUENCE OF MANAGEMMENT Trauma (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
  9. 9. Primary survey For assesment of patients in systemic fashon Establishment of treatment priorities based on injuries, vital signs, and injury mechanism Identification of life threatning conditions and their management Based on ATLS protocol.
  10. 10. PRIMARY SURVEY A-Airway management with cervical spine stabilization B-Breathing and ventilation C-Circulation with haemorrhage control D-Disability,neurological status E-Exposure and prevention of hypothermia 10
  11. 11. “A” AIRWAY PATENCY MANAGEMENT Maintenance of patency of airway must be given priority consideration, since adequate oxygenation is vital to life. 11
  12. 12. Clinical Signs & Symptoms of Respiratory Distress (Obstructions) Initially there will be restlessness, apprehension, anxiety. Tachypnoea, tachycardia, pallor. Rapid, labored breathing (gasping for breath). Rapid movement or fluttering of the alae of the nose. 12
  13. 13. Crowing sound, strider, intercostals retraction. Suprasternal indrawing of the tissues or supraclavicular retraction Decreasing ventilatory excursions, hypercarbia, hypertension. Progressive cyanosis (may be present with Hb less than 5 gm.) 13
  14. 14. Causes of respiratory obstructions related to maxillofacial injuries.  Inhalation of blood clot, vomit, saliva, thick mucosa or portions of teeth, bone and dentures  Inability to protrude the tongue, because of the posterior displacement of the anterior fragment of the mandible (Bilateral parasymphysis mandibular fracture)  Occlusion of oropharynx by the soft palate after retroposition of the maxilla (fractured maxilla) 14
  15. 15. 16 Systematic approach to airway management 1. Initial assessment : Recognize airway obstruction 2. Perform airway maneuvers, clear the airway, reposition of patient. 3. Use artificial airways, perform bag-valve-mask ventilation. 4. Perform endotracheal intubation. 5. Surgical airway if unable to intubate.
  16. 16. Airway Management Non –Surgical  Positioning of the patient  Oropharyngeal toilet  Suctioning of Vomitus  Anterior traction of the tongue  Immediate restoration of the position of soft palate. Surgical  Tracheostomy  Cricothyroidotomy 16
  17. 17. Non Surgical Treatment 1.Position of the Patient. Semi-prone position- will maintain clear airway mainly by allowin& CSF from the airway & preventing partially avulsed soft tissue g drainage of blood, saliva of the lips or cheeks from obstructing the airway. 17
  18. 18.  Supine position with head extended should be deprecated especially in spinal injuries. 18
  19. 19. 2. Oropharyngeal Toilet  All blood clot, saliva, thick mucus or foreign bodies etc. should be cleared from the oral cavity and throat by digital exploration or by using cotton swabs, if available.  Fingers of one hand maintain open mouth while fingers of other hand sweep through oral cavity removing any foreign material 19
  20. 20. 3. Suction If suction machine is available, then catheters should be used to clear the nose, oral cavity and throat. 20
  21. 21. 4. Anterior Traction of the Tongue  Control the tongue by the proper positioning of the patient; or the tongue can be pulled out and it can be maintained in the forward position by using tongue suture or towel clip attached to the patient’s shirt collar. 21
  22. 22. 5. Immediate restoration of the position of soft palate. - It can be brought about by doing disimpaction of the maxillary fracture. - This is achieved by placing index and middle finger into the mouth hooking behind the soft palate and thumb placed on the alveolus in the incisor region. - Head is stabilized by counter pressure with other hand over the fore head. - Strong anterior and downward traction will bring the maxilla in normal position. - Immediately 1 or 2 well lubricated nasopharyngeal tubes should be inserted to maintain the airway 22
  23. 23. 6. Mouth to mouth breathing  First ventilation cycle is comprised of four quick, full ventilations of the victim without allowing time for full lung deflation between breaths.  Effective artificial ventilation is noted by expansion of chest of the victim.  In normal adult minimal volume should be 800 ml but need not exceed 1200 ml. of air for adequate ventilation 23
  24. 24.  Exhalation is a passive process. - The rescuer removes his or her mouth from that of the victim, takes in a breath of fresh air, and watches the chest fall. For Adults : At a rate of one every 5 seconds (12 per minute) In children One every 4 seconds (15 per minute) In infants : One every 3 seconds (20 per minute). 24
  25. 25. Rescuer places fingers of one hand on bony anterior portion of mandible;other hand is placed on forehead and rotates the head back. It stretches soft tissues of the neck,lifting the tongue off the pharynx and opening the airway. Head-tilt,chin-lift 26
  26. 26. 7. Endotracheal intubation If the airway is compromised or its integrity is deteriorating as a result of haematoma formation, soft tissue swelling, or surgical emphysema. Types Oral & Transnasal Cuffed & uncuffed 27
  27. 27. Criteria for intubation Clinical  Shortened speech  Use of accessory muscles  Subjective air hunger  Change in mental status  Poor inspiratory force Laboratory  PaO2/fiO2<250  PaCO2>50mmHg PH < 7.25 RR >35 breaths/min 28
  28. 28. INDICATION FOR TRACHEAL INTUBATION(ATLS) Need for airway protection  Unconscious  Severe maxillofacial fractures  Risk for aspiration  Bleeding  Vomiting  Risk for obstruction  Neck hematoma  Laryngeal, tracheal injury  Stridor Need for ventilation  Apnea  Inadequate respiratory effort  Tachypnea  Hypoxia  Hypercarbia  Cyanosis  Severe closed head injury with need for hyperventilation 29
  29. 29.  In addition, two more indications are A combative patient who exacerbate potential injuries & who cannot safely be controlled by any other means & A patient who is likely to have airway or breathing difficulties in the near future. 30
  30. 30. Contraindication  Real contraindication to tracheal intubation is the ability to adequately secure & maintain an airway by less invasive means. Relative contraindication  Severe midface fractures associated with basilar skull fractures, to the nasal route.  Severe laryngeal trauma with tracheal separation-to orotracheal intubation since placement may further complicate the injury. This rare injury treated with emergency tracheostomy 31
  31. 31.  Fiberoptic techniques are generaly not successful if there are notable airway secretions, bleeding , or emesis.  Apnea is absolute contraindication to nasal intubation.  Blind intubation in the setting of major upper airway or neck injuries. 32
  32. 32. Orotracheal intubation  Preparation  Suction  Airway.  Laryngoscope.  Tube.  Equipments 33
  33. 33. 34 Airway management devices: A - oropharyngeal (Guedel) airway; B - nasopharyngeal airway; C - endotracheal tube with inflated cuff; D - laryngoscope; E - Magill forceps
  34. 34. Letter A shows the wrong and letter B shows the correct position of patient's head 35 Position of the patient
  35. 35. 36 Technique of direct laryngoscopy and orotracheal intubation. Curved blade placement in orotracheal intubation. Technique
  36. 36. Straight blade technique: 37
  37. 37. 38 Fiberoptic intubation Indications:  Routine intubation, difficult intubation, abnormal airway, compromised airway  Neck extension not desirable  Assessment of tube placement  Risk of dental damage  Removal of secretions and mucus plugs  Contraindications:  Lack of skill  Inability to oxygenate patient  Major bleeding in the airway Benumof JL. Anesthesiology 75:1086, 1991.
  38. 38. 39 Surgical airway Inability to intubate the trachea for any reason is an indication for creation of a surgical airway when less invasive methods have failed to restore an adequate airway.
  39. 39. SURGICAL Tracheostomy  In greek it means creating a window in the anterior wall of the trachea.  Tracheotomy: an incision or cutting into the trachea  It is definative management in upper airway obstruction in maxillofacial injuries. 40
  40. 40. INDICATIONSMajor laryngeal trauma with concern that cricothyrotomy or orotracheal intubation might result in retraction of trachea in to mediastinum. Inability to intubate or perform needle cricothyrotomy in a pediatric patients i.e no airway option available.  Any patient that is adequately stable, and who requires a surgical airway that can be placed in a controlled fashion in the operating room. Laryngeal foreign body or pathology (e.g tumor) that prohibits cricothyrotomy.  Prolonged ventilation.  Facilitation of management of cervical spine injuries or oncologic resections of head and neck 41
  41. 41. Contraindication  if the patient airway can be safely secured by other means( rescue airway, RSI, needle or open cricothyrotomy, etc)  In an expanding hematoma. 42
  42. 42. Complications Perioperative Hemorrhage Pneumothorax Subcutaneous emphysema Esophageal injury False passage Aspiration Post operative  Plugging of the tube with secretion  Hemorrhage  Infection  Tracheal stenosis  Tracheoesophagal fistula  Vocal cord paralysis 43
  43. 43. Procedure 44
  44. 44. 45
  45. 45. 46 46
  46. 46. 47 47
  47. 47. C spine immobilisation  Well fitting hard collar & backboards  “sandbags” 48
  48. 48. 49 Cricothyrotomy 1.Needel cricothyrotomy 2. cricothyrotomy
  49. 49. 50 Indications 1. Maxillofacial trauma; obstruction of the airway from massive facial trauma is the most common indication for cricothyrotomy. 2. Oropharyngeal obstruction; edema secondary to infection, allergic reaction, thermal and caustic injuries, foreign body, and mass lesions ; when oral or nasal intubation is not possible. 3. Conditions in which tracheal intubation from above is either contraindicated or unsuccessful, such as with congenital malformations, massive hemorrhage, persistent vomiting, intermitting laryngospasm.
  50. 50. Contraindications 1. Age: in children below age 11. 2. Crush injury to larynx: result in laryngeal separation 3. Preexisting laryngeal or tracheal pathology: obstruction secondary to tumor or subglotic stenosis might prevent the establishment of functional airway 51
  51. 51.  Needle cricothyrotomy procedure. (A) Positioning (assuming no contraindications) to expose the external anatomy (eg, laryngeal prominence).  (B) Locating the cricothyroid membrane (palpation of the cricothyroid membrane).  (C) Needle puncture of the cricothyroid membrane (anterior and side views).  (D) Seldinger (guidewire) technique for cricothyrotomy (cutaway of side view and side view) 52 Needle cricothyrotomy
  52. 52. Cricothyrotomy  Palate thyroid cartilage-inferior to the mandible & hyoid bone in the midline  Cricoid cartilage – 2 to 3 cm inferior to the thyroid cartilage.  A horizontal incision 2cm long is placed through the skin & subcutaneous tissue.  The incision is made just superior to cricoid cartilage to avoid the anastomosis of the superior thyroid & cricoid arteries.  A tracheostomy tube is placed.
  53. 53. 54
  54. 54. Complications Perioperative Improper tube placement Hemorrage Prolonged execution time Pneumomediastinum Subcutaneous emphysema Thyroid gland injury Esophageal injury Cartilage fracture Recurrent laryngeal nerve injury Post operative Dysphonia,hoarness Subglotic stenosis Infection Hemorrage Aspiration Occlusion of tube Persistent stoma Vocal cord paralysis 55
  55. 55. ADVANTAGES OF CRICOTHYROTOMY OVER TRACHEOSTOMY  Faster than tracheostomy, generally less than 2 min.  Easier to perform, with less instrumentation required.  Fewer surgical complications & less bleeding  Does not require extension of the neck. 56
  56. 56. B: Breathing  Once the patient airway has been established & the breathing sustained, the patient should be placed on supplemental oxygen.  Oxygen can be administered to the patient via nasal cannula, a face mask, or endotracheal tube.  It should be given until PaO2 >60-70mmHg.  If administered for prolonged period-oxygen toxicity 57
  57. 57. C:circulation 1. Hypovolemic shock 2. Control of bleeding 3. Fluid resuscitation 4. Blood product replacement. 58
  58. 58. Hypovolemic shock and hemorrage  Hemorrage is the most common cause of hypovolemia in the multisystem injured patient.  Physiologic response can be categorized based on percentage of blood loss. 59
  59. 59. Classes of hemorrhage CLASS I CLASS II CLASS III CLASS IV Blood volume loss Up to 15% 15% to 30% 30-40% >40% Adult blood volume amount <750 ml 750-1500ml 2000ml >2000ml Need for blood transfusion No Generally no Almost always Yes Tachycardia Minimal Present Marked Marked Systolic pressure changes None None Decreased Decreased Diastolic None Decreased Decreased Decreased Urinary output changes None Midly affected Significantly decreased Negligible urine output60
  60. 60.  While the primary assessment is taking place, ATLS dictates that a minimum of two large-bore(16 to 14 gauge) intravenous catheters should be placed in case of fluid resuscitation.  When blood loss is mild (less than 15% of blood volume), no volume resuscitation is necessary.  With moderate to severe blood loss, the only effective management of hypovolemia is volume resuscitation. 61
  61. 61.  In hypovolemic shock, a standard volume resuscitation approach is to administer 2 liters of crystalloid fluid as a bolus.  If no response, then colloid fluids are added to the regimen.  Colloids are efficient plasma expanders.  There is a 1:1 ratio of colloid replacement to blood loss and a 3:1 ratio for crystalloid replacement. 62
  62. 62. Blood product replacement  Blood transfusion is to increase the oxygen-carrying capacity of the blood  Indicated for hemoglobin less than 6 g/dL.  In case of whole blood loss-early replacement with O- negative blood can be given.  Not more 4 units of O-type blood should be administered.  A unit of FFP is given for every 5 units of blood to prevent coagulation abnormalities. 63
  63. 63.  If the patient doesn't respond to initial fluid resuscitation and/or blood transfusions, measure CVP with a catheter or evaluation of the neck veins may assist with hypovolemic shock.  Patient is placed in trendelenburg’s position to empty the large capacitance or venous side of the peripheral circulation back to heart. 64
  64. 64. Control of bleeding  Prompt control of post traumatic bleeding is a must.  Initial digital compression should be given to control the bleeding-firm & continuous.  Compression dressings also can be used.  Major vessels which are cut, should be clamped or ligated.  Soft tissue wounds which are deep and extensive should be sutured immediately  Firm pressure applied proximal to major arteries to control bleeding. 65
  65. 65.  Deep wounds also can be packed with gauze till definite measures are taken.  Nasal bleeding can be stopped by using ribbon gauze packing soaked in 1:1000 adrenaline. In some cases post nasal packing may be necessary 66
  66. 66. Method of insertion of a postnasal pack  A flexible aspiration catheter 3mm in diameter is passed via one nasal aperture and retrieved with Magill forceps from the oropharynx and it is lead out through the mouth.  A pack of about 4cm in diameter is made and is tied with tape.Two ends are left,one of each is passed into the end of catheter which is then withdrawn back through the nose.  The pack is pushed up behind the soft palate and the two ends of the tape secured together firmly below the anterior nares  67
  67. 67. Neurologic Examination(Disability)  A brief neurological evaluation is performed to establish The patient’s level of consciousness Pupillary size & reaction  Lack of consciousness with altered pupil reaction to light –immediate CT scan of the head-management with mannitol or fluid restrictions 68
  68. 68. The committee on trauma of the American college of surgeons recommends AVPU system  A rapid assessment of neurological disability is made noting patients response on a 4 point scale A - Responds appropriately, is aware V - Responds to verbal stimuli P - Responds to painful stimuli U - Does not respond, unconscious  In the absence of direct damage to the eye, pupil response must be recorded. 69
  69. 69. EXPOSURE Patient should be completely disrobed so that all the body can be visualized, palpated, and examined for injuries or bleeding sites. 70
  70. 70. Conclusion  In the care of the patient with maxillofacial injuries, it is essential that the surgeon have the knowledge and the ability to provide an emergency airway.  Surgeons must be technically prepared and psychologically willing to perform procedures that may be life saving. 71
  71. 71. References 1. Miller’s Anaesthesia. Vol. I 2. Oral and Maxillofacial trauma. 2nd edition. eds RJ Fonseca and RV Walker. 1997 3. Principles of Oral and Maxillofacial Surgery. Peterson, Marciani, Roser and Indresano. Vol. I Principles of Surgery. Part V - Principles and Management of Maxillofacial Trauma. 1997 4. Rowe and Williams’ Maxillofacial injuries. Vol. I. 2nd edition. J. Ll. Williams (ed.) 1994. 5. Oral and Maxillofacial Surgery. Vol. 3 – Trauma. RJ Fonseca(ed). 1999. 72
  72. 72. Head Injuries  C – consciousness  R – respiration  A - Trauma  N – Neck  Cervical/Carotid Injury  E- Eyes  Pupils  Extra ocular muscles  Corneal reflexes  Occulovestibular and occulocephalic reflexes  A - Airway  Gag relex  L- Limbs  Motor examination  Reflexes  Sensation
  73. 73. HEAD INJURIES These may include injuries of the scalp, skull, brain, and blood vessels. Scalp Injuries 1. Laceration of the scalp may be associated with significant bleeding. Control with deep sutures and compression dressing. Prophylactic antibiotics for Scalp infections as they may spread intracranially via the emissary veins. 2. Skull fractures are described according to shape, displacement, site and integrity of the overlying skin. Thus we have, for example, linear, stellate, comminuted, depressed, compound, and basilar fractures.  A fracture can be diagnosed by digital exploration of the wound, radiographically or clinically. The diagnosis of basilar fractures is often clinical:  CSF leaking from the nose or ear.  Periorbital ecchymosis (raccoon eyes).  Ecchymosis behind the ear (Battle's sign).
  74. 74. Physical Examination  1. Assess level of consciousness. Use the Glasgow Coma Scale. The minimum score is 3 and the maximum score is 15. An intubated patient has a maximum GCS 11T. A score of 8 or less signifies severe brain damage and the prognosis is guarded.  2. Check pupils (size, reaction to light).  3. Check ears and nose for bleeding or CSF leakage.  4. Check for ecchymosis around the eyes or behind the ears (basilar fracture).  5. Check cranial nerves.  6. Exclude neck injury (neck pain, stiffness, tenderness, or paralysis are suspicious signs).  7. Limbs (strength, tone, reflexes)  8. Vital signs (blood pressure, pulse, respiration, temperature)  9. Associated injuries
  75. 75. Brain Injuries  1. Concussion: No gross pathology. Transient loss of consciousness. CT scan is normal.  2. Contusion: Bruising of the brain surface underneath a fracture or at the under-surface of the frontal and temporal lobes, due to shearing forces. Diagnosed on CT scan.  3. Laceration: Tearing of the brain substance. Diagnosed by CT scan.  4. Brain edema: This is localized in the glial cells, myelin sheaths, and intercellular spaces. It causes increased intracranial pressure, which may impair brain circulation, or result in brain herniation. It may be missed in early CT scans. Later CT scans or MRI show edema more reliably.
  76. 76. Brain damage is classified into: 1. Primary brain damage. It occurs at the time of injury and is irreversible (i.e. lacerations, contusions, axonal injuries of the white matter due to shearing forces). 2. Secondary brain damage. It occurs at a later stage due to tissue hypoperfusion and may be preventable and reversible. Conditions that may cause secondary brain damage:  Extracranial causes: shock, hypoxia, and electrolyte abnormalities.  Intracranial causes: hematoma, brain edema, infection, and hydrocephalus A minimum CPP of 70 mm Hg (or >50 mmHg in young children) (CPP = mean arterial pressure (MAP) – intracranial)
  77. 77. Intracranial Bleeding  1. Epidural hematoma: Usually due to laceration of the middle meningial artery or venous sinuses. Commonly located in the temporal or parietal region, often with associated fractures. On CT scan it appears as a hyperdense, biconvex-shape lesion.  2. Subdural hematoma:  a. Acute subdural: It manifests within the first few hours of injury. It is due to bleeding from injured brain tissue or from the veins, which bridge the cortex with the cavernous sinus. On CT scan it appears as a crescentshape, hyperdense lesion.  b. Chronic subdural: It may appear many days, weeks or months after the injury. More common in elderly patients. On CT scan it shows as a crescent- shape, hypodense lesion.
  78. 78.  3. Intracerebral hematoma: Usually beneath a cortical contusion.  4. Subarachnoid hemorrhage: It often gives symptoms and signs of Meningial irritation: headache, photophobia, neck stiffness, fever. The mental status may vary from confusion to coma. On CT scan it appears as linear, highdensity areas following the sulci, often in the Sylvian fissure. The blood is usually absorbed by the CSF. It may cause late hydrocephalus because of obstruction of the CSF circulation.  A catastrophic complication in patients with intracranial hematomas is herniation of the temporal lobe through the tentorium and compression of the brain stem. Symptoms and signs:  1. Dilatation of the ipsilateral pupil, due to compression of the third nerve. In the early stages there may be transient constriction due to stimulation of the nerve.  2. Depressed level of consciousness, due to compression of the reticular formation  3. Contralateral hemiparesis, due to compression of the cerebral peduncle  4. Bradycardia  5. Elevated blood pressure  6. Irregular respiration
  79. 79. Ocular function  Reaction of pupils to light  Extraocular muscle function  Oculovestibular and oculocephalic reflexes  Corneal reflex  Gag reflex
  80. 80. Cranial nerve examination  Olfactory nerve  Optic nerve  Occlumotar  Trochlear  Abducent  Trigeminal nerve  Facial nerve  Vestibular nerve  Glossopharyngeal nerve  Spinal accesory nerve  Hypoglossal nerve
  81. 81. Upper motor lesion Vs lower Motor lesion  Mucle groups  Rigid  Slight wastine  Flexor spams  Brisks jerks  Plantars extensor  Normal electrical reaction  Individiual  Flaccid  Marked wasting  Fasciculation  Deep jerks absent  Flexor plantars  No or little reaction
  82. 82. Motor nerve examination  Grade 0 – no motor activity  Grade 1 – papable muscle contraction  Grade 2 – complete range of motion with gravity eliminated  Grade 3 – complete range of motion against gravity  Grade 4 - complete range of motion against gravity with resistance  Grade 5 – complete range of motion against gravity with complete resistance Gait •Casual , heal to toe and tandem walking to be examined •Cerebellar dysfunction can cause ataxia of gait •Unilateral cerebellar lesion will produce staggering toward the affected side ( typicall walk with the legs apart) Coordination •Ability to perform finger to nose, heel to shin, and rapid alternative movements •Hemispheric cerebellar disease usually lateralize, middle vermian lesions affect bilaterally
  83. 83. Sensory system  Grade 0 – absent  Grade 1 – present  Grade 2 – normal  Grade 3 – normal active  Grade 4 – hyperactive  Grade 5 – hyperactive with Clonus Jaw jerk Bicep jerk Suppinator jerk Tricep jerk Knee jerk Angle jerk Babinskis sign
  84. 84. Diagnostic tests  1. Plain skull x-rays only if CT scan is not available (may show fractures, foreign bodies, air in the skull, shifting of calcified midline structures). A linear fracture increases the risk of intracranial hematoma by 400 times.  2. Cervical spine x-rays and CT scan for all unconscious patients and those with suspicious symptoms (local tenderness, neurological signs).  3. CT scan: This is the most important diagnostic tool.  Indications: All patients with history of loss of consciousness, amnesia, depressed level of consciousness, headache and localizing signs should have a CT scan investigation. Subsequent CT scan may be necessary if there is deterioration of the neurological status.  4. Carotid angiogram (limited use). It might be useful in some penetrating injuries, especially with retained knife blades or bullet injuries.  5. Intracranial Pressure (ICP) monitoring: It is an essential diagnostic, monitoring, and therapeutic modality in severe head injuries. The CPP (Cerebral Perfusion Pressure) is much more important than ICP absolute values. Maintain a CPP >70 mmHg or >50 mmHg in young children. SEND FOR NEUROLOGICAL CONSULTATION
  85. 85. Management of Scalp injuries  Scalp lacertations:Copius irrigation to cleanse the wound, carefull debridement. Closure in layers  Scalp avulsions: copius irrigation, trimming of edges. Primary closure if avulsion is small. Large area to be covered with suitable flap or left with external dressing for secondary healing.
  86. 86. Managemet of Mild Head injury GCS 14 - 15 • History • Name/Age/Sex • Mechanism of Injur • +/- loss of consciousnes • Level of alertness • Amnesia – Retrograd/anterograde • Head ache- mild/moderate/sever • +/-seizure • GPE • Limited neurological examination • Cervical spine radiographs • Blood alcohol • CT scan • Admit/observe • No CT Scan/Abnormal CT scan • Penetrating Head Injuries • Deteroriting Condition • Moderate/sever head ache • Alcohol intoxification • Skull fracture • CSF leak • Amnesia • H/O unconsciousnes • Discharge • Schedule follow up with in 1 week
  87. 87. Management of Moderate head Injury (Flow Chart) GCS 9-13 Admission CT Scan of Brain If patient improves discharge if patient detoriates, manage as per severe head injury
  88. 88. Management in Case of Sever head injury GCS score 3-8 • ABC • Previous history for allergies, medications, past illness, last meals and events leading to head injury Neurologic Reevaluation •Eye opening •Motor response •Verbal response •Pupillary light reaction •Occulo cephalics reflex •Occulo vestibular reflex Therapeutic Agents •Mannitol •Moderate hyperventilation •Anticonvulsants if requireed • CT scans • Air Venticulogr am • Angiogram
  89. 89. Skull fractures  Skull fracture predispose a conscious to about 400 times the possibility of cranial haematoma and about 20 times in a comatose patient  Classified as:  Closed/open  Linear/stellate/communited  Depressed / non depressed
  90. 90. Management  Closed non depressed fractures:- observation and monitoring and medical line of treatment for associated intracranial parenchymal injury  Open non depressed fractures:- close observation, surgical intervation if intracranial bleed is suspected/anticipated  Depressed skull fractures:- observation, if no untoward neurological sign exists than the operation may be delayed and elevation of the fractured segment is done
  91. 91. Basal skull fractures  Associated tear of the dura and arachnoid at the base of the skull/ middle or anterior cranial fossa  Battles sign is suggestive of basal skull fracture  A CSF fistula occurs in 70 % patients with in 48 hours of trauma  98% of fistulae occur with in 3 months  Post traumatic fistulae heal spontaneously with in week, and 80% heal with in 6 months.  Spontaneous reoccurance may be there after initial cessation  Otoroheas almost always resolves spontaneously and delayed otorrhea is rare  Chronic fistulae are indicated for surgical repair
  92. 92. C/F  Headache  Decreased hearing  Salty taste in mouth  Pneumocephalus present in 30% of the patients Diagnosis Bed side: ring test tram line Lab test: glucose >30mg/dl protein < 2/l presence of b2 transferrin
  93. 93. Management  There may be presence of meningitis - Prophylactic antimicrobials (3rd generation cephalosporins)  Head elevated to 30 degrees, cautioned againts blowing nose, forcefull coughing  If leak persists for more than 72 hours, lumbar puncture is indicated to reduce ICP  Fewer than 5% patients require repair. Immediate surgical intervention is indicated only open communited fractures with CSF leak  Delayed surgical repair is indiacted in  Persistent or increased CSF leakage over 1 or 2 weeks  Presence of unresolving pneumocephalus for more than a week  meningitis
  94. 94. Cervical Spine Injuries  Only 2% incidence of cervical spine injuries in maxillofacial trauma patients  Identification of obvious fracture , widening of posterior spina process interspace  CT scan is choice of diagnostic radiographic tool  Emergency management include:  ABC  C-Spine stabilization using rigid and semi rigid collars  30mg/kg predisonolone bolus followed by 5.4g/kg/hr for 24 hours  Definitive management include skeletal traction, with the use of halo traction with stryker frame with abouts 25 pounds of traction force
  95. 95. Orbital injuries  Opthalmic exatmination: Visual accuity Enoptholmoses/proptosis/diplopia  Eye movement Size , level and reaction of pupils Intra occular examination of choroid, anterior chamber, cornea,iris  Extra ocular examination  Lid integrity  Nasolacrimal duct injury  Echymosis  Ptosis
  96. 96. 100 Hutchinson’spupil •Seen in case of cerebral compression •Consists of 3 stages Pupil of the side of injury contract due to irritation of occulomotor nerve Pupil on other side -normal pupil of the injured side becomes dilated due to paralysis of occulomotor nerve Pupil of other side contracts Pupils of both sides dilated, no reaction to light
  97. 97. 101 Pupillary response inference Bilaterally reactive pupils that react to both direct & consensual stimuli Normal pupil Bilateral small pupils Narcotics, pontine injury, early central herniation on the pons Bilateral fixed & dilated pupils Inadequate cerebral perfusion,severe elevation of ICP preventing adequate blood flow to brain Unilateral fixed & dilated pupils. pupil that does not constrict when light is directed at the pupil but constricts when light is directed to contralateral pupil Traumatic optic nerve injury (Marcus Gun pupil) A core optic pupil (pupil that appears irregular in shape) Lack of coordination of contraction of the muscle fibers of the iris and is associated with midbrain injuries Unilateral dilated pupil that does not respond to either direct or consensual stimulation Transtentorial Herniation
  98. 98. 102 Cranial nerve 3,4,6: - light reflex - intorsion and extorsion
  99. 99. Vision-threatening injuries (VTI)  These include:  Retrobulbar haemorrhage;  Traumatic optic neuropathy;  Open and Closed globe injuries;  Loss of eyelid integrity;  Chemical injury.  Loss of sight following blunt facial trauma may be crudely considered to be due to the following mechanisms.  Direct injury to the globe;  Direct injury to the optic nerve, e.g. bony impingement;  Indirect injury to the optic nerve, e.g. deceleration injury resulting in shearing, stretching forces;  As a result of a generalised or regional fall in tissue perfusion (anterior ischaemic optic neuropathy,  retrobulbar haemorrhage, nutrient vessel disruption);  Loss of eyelid integrity
  100. 100. Retrobulbar haemorrhage  A tense, proptosed globe and a dilated pupil may be the only clues to the presence of a retrobulbar haemorrhage  A lateral canthotomy, with lateral canthal tendon division, can be performed under local anaesthesia in the emergency setting. Lignocaine 1%, with adrenaline (1 in 200,000), is injected into the lateral canthal area of the affected eye, the lateral canthus incised to the orbital rim and the canthal tendon identified and cut. The lower eyelid is then pulled forward and its lateral attachment to the orbital rim divided.  This allows the globe to translate forward, partially relieving the pressure by increasing the retrobulbar volume. If necessary, the same procedure can also be applied to the upper eyelid laterally. Formal decompression is then carried out under a general anaesthesia
  101. 101. CHEST INJURIES Rib trauma is occurs in aout 56% of poly trauma patients followed by pneumothorax, flail chest, injuty to heart and major vessles Degree of injury to chest is not indicative of the severity of injury to inner structures During the Primary Survey, the following life-threatening conditions from the chest should be identified and treated:  1) Tension pneumothorax  2) Fail chest  3) Open, blowing chest wound  4) Massive hemothorax  5) Cardiac tamponade During the Secondary Survey, the following injuries should be identified and treated:  1) Contained rupture of the aorta  2) Perforation of the tracheobronchial tree  3) Perforation of the esophagus  4) Rupture of the diaphragm/trachea  5) Myocardial contusion  6) Pulmonary contusion
  102. 102. PNEUMOTHORAX Definition: The presence of free air in the pleural cavity. Symptoms and signs 1. Often asymptomatic. 2. Dyspnea, tachypnea. 3. Diminished breath sounds, hyperresonance, poorly moving hemithorax. Investigations Chest x-ray, preferably erect and in expiration
  103. 103.  HEMOTHORAX Definition: Free blood in the pleural cavity. Symptoms and signs 1. Often asymptomatic. 2. Dyspnea, tachypnea, hypovolemia. 3. Diminished breath sounds, dullness on percussion, poorly moving hemithorax
  104. 104. TENSION PNEUMOTHORAX Definition: Air under pressure in the pleural cavity due to a valve effect. Associated with life-threatening cardiorespiratory compromise due to collapse of the affected lung, compression of the normal lung and decreased venous return. Symptoms and signs Dramatic presentation. Panicky patient. Dyspnea, cyanosis, tachypnea, Shock, distended neck veins. Deviated Trachea to opposite side Absent breath sounds, hyperresonance on affected side. Prominent hemithorax with no movement on respiration
  105. 105. Flail Chest  Occur as a result of three or more contigous ribs fracturedd at two points  Lateral type of flail chest is more common  Anteior type occures when ribs become separated at the costrochondral junction, with or without associated fracture of sternum.  The posterior type occurs whe n the posterior ribs are fractured  Pulmonary contusion, hemothorax and pneumothorax may be associated with flail chest,  Mechanical ventilation is indicated  Tachyapnea  Shallow rapid breaths  Distended neck veins  hypercapnea
  106. 106. Placement of thoracic tube
  107. 107. Abdominal Injuries The abdomen is systemically examined by inspection, palpation and auscullation and percussion Injury to be suspected in deacceleration injuries, blunt trauma apart from penatrative injuries Presence of haematuria in Routine urine examinatio may indicate a renal/genito urinary trauma Serum amylase a non specific test in presence of abdominal pain is significant LFT should also be advised to check liver injuries Dignostics include USG, CT Scan PA abdomen and DPL
  108. 108. DPL (diagnostic peritonial Lavage)  Indicated in patients with + H/O abdominal trauma with abdominal pain /tenderness.  Objective is to obtain fluid from the pelvic fossa for analysis  Bladder should be emptied to avoid injury during DPL.  Aspiration of fluid is done, if no fluid is obtained tha n 20ml/kg of RL is infused upto 1 Litre and removed fluid should atleast be in range of 500-700 ml.  Three methods:  Closed type: catheter blindly inserter below the umblicus in to the peritoneal cavity. Highest incidence of complication, false negative tests and iatrogenic injury to visecral organs  Semiopen type: 2-3 cm infraumblical skin incision, blunt dissection. Incision into fascia. Insertion of trocar  Open technique: insertion of the catheter direct vision. Safest and guarantees intraperitoneal placement
  109. 109. Managemet of abdominal injuries  Physical examination to be repeated every 6 hourly  Management of shock, sepsis  Surgical exploration and intervention when necessary  Monitoring of urine output every hourly  Patient to be NPO  Nutritional support
  110. 110. Urological injuries  Occurs in 10% polytrauma patients  Majority of injuries are non threatning  Evaluation of kidneys, ureter, bladder, urethra and genitila  Excellent healing capibilities of genitourinary tract, if urinary flow can be maintained without obstruction than healing is likely with just medical intervention  Kidney is the most common urologic organ to be injured  CT scan is the gold standard for diagnosing renal injuries
  111. 111. Skeletal injuries
  112. 112. Retrograde intubation
  113. 113. Submental intubation
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