Primary assessment in maxillofacial trauma.pptx

Primary Assessment of the Maxillofacial Trauma
Patients
Dr.Kathirvel
PG-OMFS

Contents:
Initial Assessment
Assessment Principles
Primary Assessment
• Airway Maintenance with Cervical Spine Control
• Breathing
• Circulation Management
Secondary Assessment
• Face, Head, and Skull Injuries
• Neck Injuries
• Chest Injuries
• Other Potentially Life-Threatening Injuries
• Abdominal and Pelvic Trauma
• Spine and Spinal Trauma
• Maxillofacial Injuries
• Extremities and Fractures

INITIALASSESSMENT
Goal:
To recognize the patient who does have life threatening injuries, establish treatment priorities and
manage them immediately
RAYMOND J. FONSECA; oral & maxillofacial trauma; fourth edition; 2013; Saunders; Elsevier
ASSESSMENT PRINCIPLES
Outlined by the American College of Surgeons (ACS) in their guidelines regarding ATLS
protocols.
1. Preparation and transport
2. Primary survey and resuscitation - including monitoring and radiography
3. Secondary survey - including special investigations such as CT scanning or angiography
4. Ongoing reevaluation
5. Definitive care

Trauma has a trimodal distribution.
The first death peak - seconds or minutes of the injury.
Due to lacerations of the brain, brainstem, upper spinal cord, heart, aorta, or other large
vessels.
The second death peak - within the first few hours after injury.
Due to central nervous system (CNS) injury or hemorrhage.
The third death peak - days or weeks after the injury
Usually due to sepsis, multiple organ failure, or pulmonary embolism.
Peterson; 2004; Principle of oral and maxillofacial surgery; BC Decker Inc

Platinum Minutes
• “Emergency Platinum Ten Minutes (EPTM)” - emphasizes self-rescue and assisted
rescue within the first ten minutes after accidental injuries and emergencies occur.
• The goal is to reduce the mortality and the disability rates of accidental injuries and
emergencies
Golden Hour
• The term “Golden Hour” was first introduced in 1961 by R Adams Cowley
• “Golden hour” - injured patient has 1 h (60 min) from the time of injury to receive
defnitive care.
• These patients may be saved with rapid assessment and management of their
injuries during that time.

Triage
• Prioritize victims according to the severity and urgency of their injuries and
the availability of the required care.
• The goal of triage is to rapidly and accurately identify patients with life-
threatening injuries and to manage these patients with the available resources
to achieve the greatest possible outcome, while at the same time avoiding
unnecessary immediate transport of less severely injured patients

Hospital Phase:
• A fully equipped resuscitation area must be available.
• Airway equipment - laryngoscopes, endotracheal tubes, suction, tracheostomy and
cricothyrotomy kits, bougies
• IV resuscitation equipment - warmed IV crystalloid solutions, different gauge IV needles,
central line and arterial line kits
• Adequate monitors and radiologic and laboratory resources are an integral part of this
phase.

Trauma scoring system
• The scoring systems vary widely, with some relying on physiologic
scores (e.g., Glasgow Coma Scale [GCS] score, Revised Trauma Score),
and others relying on descriptors of anatomic injury (e.g., Abbreviated
Injury Score, Injury Severity Score).
• Each system has unique limitations.

Glasgow Coma Scale
Developed in 1974 by Teasdale and Jennet.
It was the first attempt to quantify the
severity of head injury.
• Motor response - level of CNS function
• Verbal response - CNS’s ability to
integrate information
• Eye opening - function of brainstem activity.
15 -fully awake, responsive and
have no problems with thinking ability
8 or fewer - you're in a coma

The Trauma Score:
• Developed by Champion and colleagues in 1981 to
quickly assess the extent of injury to vital systems
• Five variables: GCS, respiratory rate, respiratory
expansion, systolic blood pressure, and capillary
refill.
• It was later modified by Champion and coworkers
to become the Revised Trauma Score in 1989.
• The Revised Trauma Score omitted respiratory
expansion and capillary refill owing to difficulty
assessing these elements in the field

Injury Severity Score:
• The Injury Severity Score (ISS) was developed to deal with multiple traumatic injuries to
multiple organ systems.
• Scoring is based on the severity of injury to the three most injured organ systems, including
respiratory cardiovascular systems, CNS, abdomen, extremities, and skin.
• Each of the three most injured organ systems is graded from 1 (minor) to 6 (fatal).

Mechanism of Injury:
• The mechanism of injury is usually one of the first issues communicated by EMS
to the trauma team as a patient enters the trauma bay.
• The mechanism of injury can provide insight into other possible injuries that have
not yet resulted in significant changes in vital signs or physiologic function.

PRIMARY SURVEY
• Airway maintenance with cervical spine protection
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability—neurologic status
• Exposure, environmental control: Undressing the patient but preventing
hypothermia

AIRWAY MAINTENANCE WITH CERVICAL SPINE CONTROL
• The highest priority in the initial assessment of the trauma patient is the
establishment and maintenance of a patent airway.
• In the trauma patient, upper airway obstruction may be due to bleeding from oral or
facial structures, aspiration of foreign materials, facial fractures, airway structure
trauma, or regurgitation of stomach contents.
• Commonly, the upper airway is obstructed by the position of the tongue, especially
in the unconscious patient

Cervical spine injury:
• Suspect - sustaining injuries above the clavicle or with decreased
levels of consciousness
• Maintenance of the cervical spine in the neutral position is best
achieved with the use of a backboard, bindings, and purpose-built
head immobilizers.
• Avoid hyperextension or hyperflexion of the patient’s neck during
attempts to establish an airway.
• Oral airway devices are usually preferred with patients with
decreased levels of consciousness.

Airway Evaluation
1. Observation:
• Agitation, labored breathing, using accessory muscles - hypoxia
• Obtundation - accumulation of carbon dioxide or hypercarbia
• Cyanosis, a late sign, - inadequate oxygenation.
2. Listen for abnormal sounds:
• Stridor - partial obstruction of the airway.
• Hoarseness - functional laryngeal obstruction.
3. Palpate the trachea and determine whether it is in the midline

Hutchison et al.
(1) Posteroinferior displacement of a fractured maxilla parallel to the inclined plane of the base of the
skull may block the nasopharyngeal airway.
(2) A bilateral fracture of the anterior mandible may cause the fractured symphysis and the tongue to
slide posteriorly and block the oropharynx in the supine patient.
(3) Fractured or exfoliated teeth, bone fragments, vomitus, blood, and secretions as well as foreign
bodies, such as dentures, debris, and shrapnel, may block the airway anywhere along the oropharynx
and larynx.
(4) Hemorrhage from distinct vessels in open wounds or severe nasal bleeding from complex blood
supply of the nose may also contribute to airway obstruction.
(5) Soft tissue swelling and edema which result from trauma of the head and neck may cause delayed
airway compromise.

Steps to stabilise the airway
1. High flow oxygen is given at 15 litres/min.
2. A jaw thrust should be performed.
3. Chin lift or head tilt should be avoided if in case C-spine injury is suspected.
4. An oropharyngeal airway is considered if the GCS<8.
5. A nasopharyngeal airway should be avoided.
6. Orotracheal intubation should be attempted only if one is confident of it, otherwise a
cricothyroidotomy should be performed and the anaesthetist called for.
7. In unsuccessful orotracheal intubation or “cannot ventilate cannot intubate situation” perform
surgical airway

The jaw-thrust procedure - placement of both hands along the
ascending ramus of the mandible at the mandibular angle. The fingers
are placed behind the inferior border of the angle, and the thumbs are
placed over the teeth or chin. The mandible is then gently pulled
forward with the fingers at the angle and rotated inferiorly with
pressure from the thumbs. The jaw-thrust procedure is the safest
method of jaw manipulation in a patient with a suspected cervical
injury.
The chin-lift procedure - placing the thumb over the incisal edges of
the mandibular anterior teeth and wrapping the fingers tightly around
the symphysis of the mandible.

Surgical Airway
Needle Cricothyroidotomy:
Locating the cricothyroid membrane:
a. By palpating the trachea just above the sternal notch and proceed
upward until the prominence of the cricoid cartilage is identified
b. By palpating the thyroid notch and proceeding downward until
the prominence of the cricoid cartilage is identified
• A needle is inserted into the cricothyroid membrane.
• A jet system is then connected, which will provide oxygen until
a more definitive airway can be established.
• Temporary airway - can be oxygenated for a maximum of 30 to
45 minutes.

Surgical Cricothyroidotomy:
• A surgical incision made on the skin,
extending to the cricothyroid membrane.
• A hemostat or scalpel handle may be used to
dilate the opening, followed by the insertion
of a small-caliber tube into the trachea (5 to 7
mm outer diameter).
• This is not recommended for children because
of potential damage to the cricoid cartilage

Breathing and ventilation
• Once a patent airway is verified or established, pulmonary function should be
assessed.
• The lungs, chest wall, and diaphragm must all function adequately to ensure proper
ventilation.
• Inadequate ventilation may result in hypoxemia, hypercarbia, cyanosis, depressed
level of consciousness, bradycardia, tachycardia, hypertension, and/or hypotension.
• Breathing evaluation is most readily accomplished by visual inspection and palpation
of thoracic cage movement and auscultation of gas entry.

Examination:
• Chest should be fully exposed and inspected for any signs of obvious injury.
• Presence of bruising, flail chest, penetration, and bleeding should be noted.
• The chest should be palpated for signs of rib or sternal fractures. Any subcutaneous
emphysema should be appreciated.
• Chest expansion should be equal bilaterally, without intercostal or supraclavicular
muscle retractions during respiration.
• The patient is assessed for inequalities in chest movement from one side to the other,
crepitus and local movement asymmetry, as in paradoxic thoracic cage movement in
flail chest.

CIRCULATION
• In the primary survey, circulation becomes the priority after airway and breathing
have been definitively managed.
• The main cause of deaths that can be prevented is caused by hemorrhage.
• Shock in a trauma patient is primarily hypovolemic secondary to trauma, although
the patient may present with cardiogenic, neurogenic, or even septic shock.
• Extensive damage to the CNS or spinal cord may result in a neurogenic shock.

ASSESSMENT
• Level of consciousness: Cerebral perfusion indicates an adequate circulating volume of blood
• Pulse: Rapid pulse may indicate blood loss whereas an irregular pulse may indicate cardiac
dysfunction.
• Respiratory rate: According to the degree of hemorrhage present, patients may become
tachypneic as a physiologic response to the need for more oxygen to be delivered to the tissues.
• Skin color: A gray, pale ashen tone may indicate hypovolemia; pink skin is an indication of
good perfusion.
• Urinary output: . A decrease of urinary output to less than 30 mL/hr in an adult may indicate
hypovolemia in the absence of other medical conditions (e.g., renal damage).

Management of bleeding
in maxillofacial trauma

DISABILITY
During the acute resuscitation period, a brief assessment of neurologic status
should be performed.
A recommended system is the AVPU method:
A—Patient is awake, alert, and appropriate.
V—Patient responds to voice.
P—Patient responds to pain.
U—Patient is unresponsive.

EXPOSURE
• Patients should be completely disrobed during the initial assessment and the
subsequent secondary survey.
• This helps ensure the observation and assessment of significant injuries.
• At the same time, efforts to prevent significant hypothermia using a warm ambient
room (82° to 86° F [28° to 30° C]), overhead heating, and warmed IV fluids, should be
instituted.

SECONDARY ASSESSMENT
• It is initiated once the primary assessment has been completed and management of
life threatening conditions has begun.
• The secondary assessment includes a subjective and objective evaluation of the
injured patient.
Subjective assessment
• A subjective assessment should include a brief interview with the patient, if
possible.
• A brief health history can be useful, including medications; allergies; previous
surgery; a history of the injury; and the location, duration, time frame, and intensity
of the chief complaint.
• Obviously, the comatose patient cannot provide useful subjective information, but
family members, bystanders, or other victims may provide some details.

The history should include an assessment based on the following protocol.
AMPLE acronym:
A - allergies;
M - medications;
P - past medical, surgical, and social history;
L - last meal; and
E - events leading to injury, scene findings, notable interventions and recordings en
route to the hospital.

Objective assessment
• Should involve inspection, palpation, percussion and auscultation of the patient
from head to toe.
• Each segment of the body (head and skull, chest, maxillofacial area and neck,
spinal cord, abdomen, extremities, and neurologic condition) is evaluated to
provide a baseline of the patient’s present condition.

FACE, HEAD, AND SKULL INJURIES
• Hemotympanum and the presence of bruising around the eyes (raccoon eyes)
and mastoid process (Battle sign) suggest a basal skull fracture.
• Patients with lateralizing signs and those with an altered level of consciousness
(GCS score < 14) should undergo cranial computed tomography (CT) scanning
• Cranial injuries can cause an ischemia as a result of elevated ICP and pressure
on intracranial vessels from an expanding hematoma.
• Failure to control an increased ICP is the most common cause of death in
hospital patients with head injuries.

Hematomas
Epidural Hematoma
• Epidural hematomas result from the tear of the medial
meningeal artery .
• The hematoma materializes between the dura and inner
table of the skull.
• The shape is biconvex or lenticular.

Subdural Hematoma
• Subdural hematomas develop from the shearing of small
surface or bridging blood vessels of the cerebral cortex.
• The shape follows more along the contour of the brain and
are more common than epidural hematomas.
Contusion or Intracerebral Hematoma
• Contusion or intracerebral hematomas occur frequently in
the frontal and temporal lobes.
• Requires surgical evacuation.

NECK INJURIES
• Penetrating injuries of the neck may require
angiographic, bronchoscopic, or radiologic
examination, depending on the level of injury (i.e.,
zone I, II, or III).
• In particular, zone II injuries that violate the platysma
may be readily explored.
• Those injuries that correlate to zone I or III benefit
from additional investigation because of the difficulty
in identifying and controlling injuries in those zones.

CHEST INJURIES
Chest injuries are directly responsible for more than 25% of the 50,000 to 60,000
fatalities annually
• Pneumothorax
• Open pneumothorax
• Hemothorax
• Flail chest
• Cardiac tamponade
may develop after the primary assessment and must be treated accordingly.

Open pneumothorax
• An open pneumothorax is due to a defect in the chest wall, allowing
air to be moved in and out of the pleural cavity with each respiration
Tension Pneumothorax:
• A tension pneumothorax develops when the injury acts as a one-way
valve through the chest wall
• A dangerous progressive increase of intrapleural pressure develops as air
enters the pleural cavity on inspiration but cannot escape on expiration,
causing complete collapse of the affected lung.

Hemothorax
• A hemothorax is a collection of blood within the pleural cavity.
• When evaluating a patient with reduced breath sounds and dull percussion to one
lung field and who also has a history of sustaining penetrating or blunt chest trauma,
a hemothorax should be suspected.
Flail Chest
• A flail chest is a fracture in multiple sites along the rib,
creating an unstable fragment of chest wall.
• This fragment moves paradoxically during respiration,
moving inward with inspiration and outward with
expiration.

OTHER POTENTIALLY LIFE-THREATENING INJURIES
Traumatic Esophageal Rupture
• Traumatic esophageal rupture occurs as a direct result of penetrating trauma
• Thus, the gastric contents leak into the mediastinum, resulting in mediastinitis
or pleural space empyema.
• Treatment mandates a direct repair with wide drainage of the mediastinum
and pleural space.

Traumatic Diaphragmatic Injury
• Blunt trauma may result in large tears of the
diaphragm, whereas penetrating trauma will
produce small tears.
• It is usually missed in the x-rays.
• Treatment consists of direct repair.

ABDOMINALAND PELVIC TRAUMA
Duodenal Injuries
• Duodenal injuries occur as a result of a direct blow to the abdomen.
• This trauma is often seen in unrestrained drivers in MVAs or in bicycle riders
who sustain a frontal collision.
• X-ray films will show retroperitoneal gas
• The gastric aspiration will show blood.

Genitourinary Injuries
• A traumatic impact to the back may result in renal abdominal
injuries.
• These may present with gross hematuria, microscopic hematuria in
patients with penetrating abdominal wounds and hypotension.
Small Bowel Injuries
• Small bowel injuries occur in the process of deceleration, with
tearing at a fixed point.
• Typically, these patients will show ecchymosis in the lower
abdomen resulting from the seat belt (seat belt sign).

Solid Organ Injuries
• Injuries to the liver and/or spleen could be present in an unstable patient.
• A laparotomy is indicated in patients in whom injury to these organs is suspected,
with evidence of hemodynamic instability or shock.
Pelvic Fractures
• Pelvic fractures are frequently the result of high-impact
injuries associated with extensive blood loss.
• Simple immobilization with a sheet will decrease the pelvic
volume.
• Rapid transportation to a trauma center is essential.

SPINE AND SPINAL TRAUMA
• Spine and spinal injury should always be suspected in the trauma patient
• These patients should be immobilized during transport.
• The initial evaluation should be followed by lateral cervical x-rays and chest and pelvic
radiography.
• If a patient is unconscious, a craniocervical 2-mm-thick CT scan should be obtained.
• If this study is negative, magnetic resonance imaging (MRI) is the preferred study of
choice for excluding instability.

MAXILLOFACIAL INJURIES
Possible for maxillofacial injuries to result in airway compromise because of the
following:
• Blood and secretions
• Mandibular fracture that allows the tongue to fall posteriorly against the
posterior wall of the pharynx
• Midface injury that causes the maxilla to fall inferiorly and posteriorly into the
nasopharynx
• Foreign debris, such as avulsed teeth or dentures.

Examination:
Extra oral:
• The face should be examined for asymmetry, discolorations, or
swelling suggestive of bony or soft tissue injury.
• Eyelids should be elevated to examine for neurologic and possible
ocular damage.
• All bony landmarks should be palpated for signs of crepitus, steps, or
other irregularities.
• Palpation should include the supraorbital, lateral, and infraorbital rims,
malar eminences, zygomatic arches, nasal bones, maxilla, and
mandible.

Examination:
Intra oral:
• An oral cavity examination should include an
evaluation of lost teeth, lacerations and
alterations in the occlusion.
• Teeth avulsed at the time of injury must be
accounted for because the tooth may have been
inadvertently aspirated or swallowed.

Primary assessment in maxillofacial trauma.pptx

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