advance trauma life support maxillofacial trauma etiology

1. MAXILLOFACIA TRAUMA
-CHAPTER ONE-
ADVANCE TRAUMA LIFE SUPPORT
DR. HAYDAR MUNIR SALIH
BDS, PHD (BOARD CERTIFIED)

2. James K Styner
1976

4. 1980

5. Styner himself recertified as an ATLS instructor, teaching his
Instructor Candidate course in Nottingham in the UK, July
2007

6.  The Advanced Trauma Life Support (ATLS)
system was therefore created initially in the USA
and rapidly taken up globally. At present, over
50 countries worldwide are actively providing
the ATLS course to their physicians

7. The steps in the ATLS philosophy
■ Primary survey with simultaneous
resuscitation – identify And treat what is killing
the patient
■ Secondary survey – proceed to identify all
other injuries
■ Definitive care – develop a definitive
management plan

8. PRIMARY SURVEY AND
RESUSCITATION
A – Airway maintenance and cervical spine
protection
B – Breathing and ventilation
C – Circulation with haemorrhage control
D – Disability: neurological status
E – Exposure: completely undress the patient and
assess for other injuries
F- Frequent reassessment must be made

10. I. Airway and cervical spine control
 All patients who have been subjected to maxillofacial
or head trauma should be presumed to have
sustained a cervical spine injury until proven
otherwise, therefore the cervical spine should be
immobilized in the neutral position by means of a
semi-rigid cervical collar or spinal board until
definitive radiographs showing all seven cervical
vertebrae and the first thoracic vertebra are taken to
rule out cervical injury

12. I. Airway and cervical spine control
The most important factor controlling
the patency of the airway in a patient
with facial injuries is the level of
consciousness

14. Several techniques exist to provide an
unobstructed airway;
1. Chin lift and jaw thrust
2. A careful examination of the oral cavity
3. Insertion of oropharyngeal or nasopharyngeal airway
4. Temporary reduction and stabilization of anterior
mandibular fractures
5. Endotracheal intubation
6. Surgical airway is obtained by cricothyroidotomy (also
known as cricothyrotomy) or tracheostomy

15. Chin lift and jaw thrust

16. oropharyngeal or nasopharyngeal
airway

17. Temporary reduction and stabilization of
anterior mandibular fractures

18. Endotracheal intubation

19. Cricothyroidotomy
 Cricothyroidotomy is the fastest and safest
method of obtaining a surgical airway. Needle
Cricothyroidotomy is a temporary procedure that
is used to oxygenate patients (for approximately
45 minutes) while a definitive airway is being
quickly prepared
 In surgical Cricothyroidotomy the cricothyroid
membrane, which is usually superficial and
palpable, is perforated with a scalpel blade

20. Cricothyroidotomy

21. Cricothyroidotomy
Needle Cricothyroidotomy Surgical Cricothyroidotomy

22. Surgical tracheostomy
 an incision is made halfway between cricoid
cartilage and suprasternal notch, dissection
continues down to the 2nd and 3rd tracheal
rings, then a window is excised through the
trachea and the tracheostomy tube is
inserted and secured.

23. Surgical tracheostomy

24. Surgical tracheostomy

25. Indications for tracheostomy in
maxillofacial injuries
1. When prolonged artificial ventilation is necessary
2. To facilitate general anesthesia during surgical repair of
complex facial injuries.
3. To ensure a safe postoperative recovery after extensive
surgery.
4. Following obstruction of the airway from laryngeal edema or
occasionally direct injury to the base of the tongue and
oropharynx.
5. Following serious hemorrhage into the airway, particularly
when a further secondary hemorrhage is a possibility.

26. II. Breathing and ventilation
Pneumothorax

27. II. Breathing and ventilation
Hemothorax

28. Flail chest

29. III. Circulation and hemorrhage control
 Definitive bleeding control is essential, along with
appropriate replacement of intravascular volume.
 The majority of fractures of the facial skeleton are
relatively closed injuries and life-threatening
hemorrhage is uncommon and hemorrhagic shock is
unusual
 Clinically significant blood loss can occur in patients
with panfacial fractures

30. III. Circulation and hemorrhage control
 Bleeding can occur from (1) external wounds,
such as the scalp which can be controlled by
direct manual pressure on the wound or by
suturing. Obvious bleeding vessels should be
secured with artery forceps, ligated if possible

31. 1. EXTERNAL WOUNDS

32. Circulation and hemorrhage control
Another source of bleeding can occur
from (2) grossly displaced fracture of the
mandible or midface, this can be
controlled by manual reduction of the
fracture and temporary immobilization
either manually, or by means of a stay
wire.

33. (fracture mandible)
Temporary fixation by stay wireDisplaced fracture mandible
2. Grossly displaced fracture

34. 3. Epistaxis & bleeding from
nasopharynx

35. Anterior nasal packing
Posterior nasal packing

36. Additional uncommon bleeding
control measures
 Ligation of
the named
vessels

37. Resuscitation fluid
 The resuscitation fluid can be crystalloid,
colloid, or blood,
 if crystalloid is used, it should be transfused
in the ratio of 3 mL of crystalloid to 1 mL
blood;
 an appropriate initial bolus in an adult patient
would be 2000 mL transfused as quickly as
possible (or 20 mL/kg in the child). The
response of the patient can be assessed,

38. Resuscitation fluid

40. Resuscitation fluid
 Urine output is a sensitive indicator of cardiac
output. Therefore placement of a urinary
catheter is essential in all significant trauma
patients. Urine output levels below 0.5 mL/kg
body weight per hour for an adult, 1 mL/kg
body weight per hour for a child and 2 mL/kg
body weight per hour for a child younger than 1
year old suggest inadequate fluid replacement.

42. IV. Disability due to neurological deficit
A V P U
A: Alert.
V: Voice, able to respond to verbal command.
P: respond to Painful stimuli.
U: Unresponsive

43. Ipsilateral dilating pupil after
maxillofacial trauma may be due to:
Direct injury to the eye
Optic nerve damage
Oculomotor nerve compression
It may be a sign of an increase in
intracranial pressure especially when
combined with decreased level of
consciousness

45. Glasgow coma scale

46. V. Exposure and environment
 All trauma patients must be fully exposed.
Therefore the environment must be warm
and appropriately protected to ensure that
the patient suffers no further harm by being
exposed to the surrounding ambient
temperature. The patient should be fully
examined including an examination of the
back, if necessary, by using a logroll
technique to ensure that otherwise hidden
areas have been inspected

47. Secondary Survey
Review of patient’s history (AMPLE)
■ Allergy
■ Medication including tetanus status
■ Past medical history
■ Last meal
■ Events of the incident

48. Definitive care and transfer
 it is important to recognize that there should
be as little delay as possible in reaching this
stage. Much has been made of the ‘golden
hour’ concept, and one often finds that the
majority of patients spend this hour at the
scene of injury

49. “
”
Maxillofacial Trauma

50. Etiology
1. Road traffic
accident

51. Etiology
2. Assaults and
interpersonal
violence

52. Etiology
3. Fall

53. Etiology
4. Sport related
injury's

54. Etiology
5. Work related
injury's

55. Etiology
6. Gunshot or
missile injuries

56. Preliminary management of
maxillofacial injuries
Mortality from trauma with 3 clearly defined peaks
1. within seconds or minutes of the event (such as severe
injury to the brain and the major cardiovascular
structures )
2. occurs some minutes to 1 or more hours after the
event (such as airway compromise, hemorrhage, and
head injury. )
3. occurs days to weeks after the event (when sepsis or
multi organs failure occur and lead to death)