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PRIMARY ASSESSMENT AND
PREOPERATIVE MANAGEMENT OF
MAXILLOFACIL AND HEAD INJURIES
INDIAN DENTAL ACADEMY
Leader in continuin...
INTRODUCTION

www.indiandentalacademy.com
DEATHS FOLLOWING RTA’S
Immmediate deaths (50 per cent)
Early deaths (30 per cent)
Late deaths (20 per cent)

www.indianden...
TRIMODAL DISTRIBUTION OF DEATH

www.indiandentalacademy.com
STEPS IN MANAGEMENT
Primary survey- identify what is killing the
patient.
Resuscitation- treat what is killing the
patient...
PRIMARY SURVEY AND
RESUSCITATION
Primary survey of the patient follows a strict
sequential protocol.
Airway and Cervical s...
CERVICAL SPINE
There should be high index of suspicion for
cervical spine injury in the patient with
maxillofacial injurie...
CERVICAL SPINE
Assume injury to cervical spine if –
Blunt trauma above clavicles
Head injury
Maxillofacial trauma
Multiple...
CERVICAL SPINE CONTROL
Definitive cervical spine
control requires the
application of semi rigid
cervical collar, sandbags
...
CERVICAL SPINE CONTROL

In the restless and agitated patient, immobilizing
the head and neck while allowing the rest of th...
AIRWAY
Assessment must rapidly be made as to
whether the patient can maintain and
protect his own airway.
If the patient i...
AIRWAY
Teeth, dentures, vomitus, hematoma and
other foreign bodies may block the airway
- right main bronchus - susceptibl...
AIRWAY
Hemorrhage may result from several causes
to obstruct the airway.
Bleeding from vessels in open wounds can
be contr...
The fractured
nose may need
to be packed
as a result of
damage to the
anterior or
posterior
ethmoidal
vessels or the
maxil...
AIRWAY
The tongue can often fall back and
obstruct the airway in unconscious
patients and in these a simple chin lift or
j...
CHIN LIFT
Chin lift should be
performed without
hyperextending the
neck.
The mandible is gently
lifted upward using the
fi...
JAW THRUST
Jaw thrust is performed
by grasping the angles
of the mandible with
one hand on each side
and displacing the
ma...
TONGUE STAY SUTURE

www.indiandentalacademy.com
INDICATIONS FOR DEFINITIVE AIRWAY
Apnea
Inability to maintain patent airway by other
means
need to protect the lower airwa...
DEFINITIVE AIRWAY
This provides oxygen assisted ventilation
via a cuffed tube present in the trachea
with the cuff inflate...
ALOGRITHM LEADING TO
SURGICAL AIRWAY

www.indiandentalacademy.com
CRICOTHYRIODOTOMY

www.indiandentalacademy.com
CRICOTHYRIODOTOMY

www.indiandentalacademy.com
CRICOTHYRIODOTOMY

www.indiandentalacademy.com
TRACHEOSTOMY

www.indiandentalacademy.com
TRACHEOSTOMY

www.indiandentalacademy.com
TRACHEOSTOMY

www.indiandentalacademy.com
TRACHEOSTOMY

www.indiandentalacademy.com
TRACHEOSTOMY

www.indiandentalacademy.com
SUPPLEMENTAL OXYGEN
Supplemental oxygen delivered through a
well-fitting re-breathing mask at a rate of l5
litres per minu...
BREATHING AND VENTILATION
Once the airway has been secured, breathing and
ventilation must be assessed.
Direct trauma to t...
BREATHING AND VENTILATION
Thoracic injuries that are immediately life
threatening include
Flail chest
Tension pneumothorax...
EXAMINATION
All the clothes covering the front and sides of the
patients chest must be removed.
The respiratory rate, effo...
FLAIL CHEST
This occurs when a segment of the chest
wall looses bony continuity with the rest of
the thoracic cage, usuall...
FLAIL CHEST
Initial treatment includes adequate
ventiliation, administration of humidified
oxygen and fluid resuscitation....
OPEN PNEUMOTHORAX
Large defects of the chest wall which remain
open result in an open pneumothorax.
If the opening in the ...
OPEN PNEUMOTHORAX
Initial management is by promptly closing
the defect with a sterile occlusive dressing
large enough to o...
TENSION PNEUMOTHORAX
Tension pneumothorax develops when a
one way valve air leak occurs either from
the lung or through th...
TENSION PNEUMOTHORAX
Chest pain
Air hunger
Respiratory distress
Tachycardia
Hypotension
Tracheal deviation
Unilateral abse...
TENSION PNEUMOTHORAX
It requires immediate decompression by
inserting a large bore needle into the
second intercostal spac...
MASSIVE HEMOTHORAX
This results from a rapid accumulation of more
than 1500 ml blood in the chest cavity.
It is most commo...
CARDIAC TAMPONADE
Cardiac tamponade results commonly from
penetrating injuries, but blunt injury may
also cause the perica...
CIRCULATION WITH HEMORRHAGE
CONTROL
Shock is defined as an abnormality of the
circulation that results in inadequate organ...
Classification and signs of hypovolemic shock
(in an adult assuming a
70 kg patient with normally 5 litres of circulating ...
HEMORRHAGE
Hemorrhage is an acute loss of circulating
blood volume.
After airway and breathing, the initial
treatment of s...
MANAGEMENT OF HEMORRHAGE
The priority is to control the source of
hemorrhage.
External hemorrhage - controlled by direct
m...
FLUID REPLACEMENT
The aim of fluid management in hypotensive
resuscitation - restore critical organ perfusion.
Therefore i...
BLOOD REPLACEMENT
Either whole blood or packed cells can he
used to resuscitate the trauma patient.
The main purpose in tr...
DISABILITY (NEUROLOGICAL
EVALUATION)
A rapid evaluation is performed at the end
of the primary survey and this establishes...
GLASGOW COMA SCALE

www.indiandentalacademy.com
Exposure and environment
The patient should be completely undressed
to facilitate a thorough examination and
assessment.
A...
Secondary survey
This does not begin until the primary
survey has been completed and the
patient stabilized.
It is a head ...
HISTORY
A through history should be taken from the
patient and family.
Allergies
Medications currently used
Past illness
P...
PHYSICAL EXAMINATION
Head
Neck
Spinal cord
Chest
Abdomen
Musculoskeletal

www.indiandentalacademy.com
DIAGNOSIS OF MAXILLOFACIAL
INJURIES
Inspection
Palpation
Diagnostic Imaging

www.indiandentalacademy.com
INSPECTION
Hemorrhage
Otorrhea
Rhinorrhea
Contour deformity
Ecchymosis
Edema
Continuity defects
Malocclusion
www.indianden...
SCALP AND SKULL
Examination should commence with an
inspection of the scalp for contusions and
lacerations concealed by th...
www.indiandentalacademy.com
EARS
The external
auditory meati
should be inspected
for discharges of
blood and CSF.

www.indiandentalacademy.com
ORBIT EVALUATION
Periorbital edema and
ecchymosis
Gross visual acuity
Diplopia
Pupillary size and shape
Subconjunctival
he...
NOSE

www.indiandentalacademy.com
CSF RHINORRHEA

www.indiandentalacademy.com
NOE FRACTURES
 Nasal fracture
comminuted with post. disp.
widened nasal bridge
splaying of nasal complex

 Epistaxis
 S...
MID FACE FRACTURE
Inspection of the face in a
typical b/l fracture of the
maxilla
Bilateral circumorbital
ecchymosis
Gross...
www.indiandentalacademy.com
MAXILLARY MOBILITY

www.indiandentalacademy.com
PERCUSSION

www.indiandentalacademy.com
TESTING FOR SENSATION

www.indiandentalacademy.com
PALPATION OF SUPRAORBITAL RIDGE &
FZ REGION

www.indiandentalacademy.com
ZYGOMATIC BONE AND ARCH
INFRAORBITAL RIDGE

www.indiandentalacademy.com
MANDIBLE

www.indiandentalacademy.com
TEMPOROMANDIBULAR JOINT

www.indiandentalacademy.com
COMPRESSION TEST

www.indiandentalacademy.com
INTRAORAL

www.indiandentalacademy.com
Guerin’s sign

www.indiandentalacademy.com
FURTHER MANAGEMENT

www.indiandentalacademy.com
GOD GAVE YOU EARS, EYES AND
HANDS; USE THEM ON THE PATIENT
IN THAT ORDER.
Sir William Kelsey Fry

www.indiandentalacademy....
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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Ap (nx power lite) /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Ap (nx power lite) /certified fixed orthodontic courses by Indian dental academy

  1. 1. PRIMARY ASSESSMENT AND PREOPERATIVE MANAGEMENT OF MAXILLOFACIL AND HEAD INJURIES INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. INTRODUCTION www.indiandentalacademy.com
  3. 3. DEATHS FOLLOWING RTA’S Immmediate deaths (50 per cent) Early deaths (30 per cent) Late deaths (20 per cent) www.indiandentalacademy.com
  4. 4. TRIMODAL DISTRIBUTION OF DEATH www.indiandentalacademy.com
  5. 5. STEPS IN MANAGEMENT Primary survey- identify what is killing the patient. Resuscitation- treat what is killing the patient. Secondary survey- proceed to identify all other injuries. Definitive care- develop a definitive management plan. www.indiandentalacademy.com
  6. 6. PRIMARY SURVEY AND RESUSCITATION Primary survey of the patient follows a strict sequential protocol. Airway and Cervical spine control. Breathing and Ventilation. Circulation and Hemmorhage control. Disability = Neurological status. Exposure + Environment. www.indiandentalacademy.com
  7. 7. CERVICAL SPINE There should be high index of suspicion for cervical spine injury in the patient with maxillofacial injuries or multisystem trauma, if the patient has an altered level of consciousness or if there is history of high speed impact. www.indiandentalacademy.com
  8. 8. CERVICAL SPINE Assume injury to cervical spine if – Blunt trauma above clavicles Head injury Maxillofacial trauma Multiple trauma www.indiandentalacademy.com
  9. 9. CERVICAL SPINE CONTROL Definitive cervical spine control requires the application of semi rigid cervical collar, sandbags placed on either side of the head and tapes over the forehead and chin, immobilizing the head and neck to the trolley. www.indiandentalacademy.com
  10. 10. CERVICAL SPINE CONTROL In the restless and agitated patient, immobilizing the head and neck while allowing the rest of the body to move can damage the cervical spine and here just a semirigid collar is acceptable. www.indiandentalacademy.com
  11. 11. AIRWAY Assessment must rapidly be made as to whether the patient can maintain and protect his own airway. If the patient is able to respond verbally, the airway, at least for the time being, is patent but repeated assessment is prudent. www.indiandentalacademy.com
  12. 12. AIRWAY Teeth, dentures, vomitus, hematoma and other foreign bodies may block the airway - right main bronchus - susceptible. Earlv in the primary survey, the oral cavity should be cleared using a finger sweep followed by aspiration. www.indiandentalacademy.com
  13. 13. AIRWAY Hemorrhage may result from several causes to obstruct the airway. Bleeding from vessels in open wounds can be controlled by pressure with gauze swabs. Soft tissue swelling and edema resulting from trauma to the oral cavity may compromise the airway. www.indiandentalacademy.com
  14. 14. The fractured nose may need to be packed as a result of damage to the anterior or posterior ethmoidal vessels or the maxillary artery. www.indiandentalacademy.com
  15. 15. AIRWAY The tongue can often fall back and obstruct the airway in unconscious patients and in these a simple chin lift or jaw thrust maneuver can be used to correct the tongue position and open the airway. www.indiandentalacademy.com
  16. 16. CHIN LIFT Chin lift should be performed without hyperextending the neck. The mandible is gently lifted upward using the fingers of one hand placed under the chin. The thumb of the same hand lightly depresses the lower lip to open the mouth. www.indiandentalacademy.com
  17. 17. JAW THRUST Jaw thrust is performed by grasping the angles of the mandible with one hand on each side and displacing the mandible forward. www.indiandentalacademy.com
  18. 18. TONGUE STAY SUTURE www.indiandentalacademy.com
  19. 19. INDICATIONS FOR DEFINITIVE AIRWAY Apnea Inability to maintain patent airway by other means need to protect the lower airway from blood or vomit potential compromise of the airway, e.g. following inhalational injury, facial fractures etc. The presence of a closed head injury requiring assisted ventilation (GCS ≤ 8) An inability to maintain adequate oxygenation by face mask oxygen supplementation. www.indiandentalacademy.com
  20. 20. DEFINITIVE AIRWAY This provides oxygen assisted ventilation via a cuffed tube present in the trachea with the cuff inflated and the tube secured in place with a tape. Three types Orotracheal intubation Nasotracheal intubation Surgical (cricothyroidotomy & tracheostomy) www.indiandentalacademy.com
  21. 21. ALOGRITHM LEADING TO SURGICAL AIRWAY www.indiandentalacademy.com
  22. 22. CRICOTHYRIODOTOMY www.indiandentalacademy.com
  23. 23. CRICOTHYRIODOTOMY www.indiandentalacademy.com
  24. 24. CRICOTHYRIODOTOMY www.indiandentalacademy.com
  25. 25. TRACHEOSTOMY www.indiandentalacademy.com
  26. 26. TRACHEOSTOMY www.indiandentalacademy.com
  27. 27. TRACHEOSTOMY www.indiandentalacademy.com
  28. 28. TRACHEOSTOMY www.indiandentalacademy.com
  29. 29. TRACHEOSTOMY www.indiandentalacademy.com
  30. 30. SUPPLEMENTAL OXYGEN Supplemental oxygen delivered through a well-fitting re-breathing mask at a rate of l5 litres per minute to achieve maximum oxygenation of the tissues, should be given to every trauma patient. www.indiandentalacademy.com
  31. 31. BREATHING AND VENTILATION Once the airway has been secured, breathing and ventilation must be assessed. Direct trauma to the chest - pain with breathing and leads to rapid shallow breathing - hypoxemia. Intracranial injury - abnormal patterns of breathing and compromise the adequacy of ventilation. Cervical spinal cord injury - diaphragmatic breathing and interfere with the ability to meet increased oxygen demands. www.indiandentalacademy.com
  32. 32. BREATHING AND VENTILATION Thoracic injuries that are immediately life threatening include Flail chest Tension pneumothorax Open pneumothorax Massive hemothorax Cardiac tamponade These should be identified in the primary survey. www.indiandentalacademy.com
  33. 33. EXAMINATION All the clothes covering the front and sides of the patients chest must be removed. The respiratory rate, effort and symmetry should be recorded, because these are sensitive indicators of underlying pulmonary contusion, hemothorax, pneumothorax and fractured ribs. www.indiandentalacademy.com
  34. 34. FLAIL CHEST This occurs when a segment of the chest wall looses bony continuity with the rest of the thoracic cage, usually as a result trauma associated with multiple rib fractures. Associated pain with chest wall movement and underlying lung injury add to the patient’s hypoxia. www.indiandentalacademy.com
  35. 35. FLAIL CHEST Initial treatment includes adequate ventiliation, administration of humidified oxygen and fluid resuscitation. Definitive treatment - re-expand the lung, ensure oxygenation, administer fluids and provide analgesia to improve ventilation. www.indiandentalacademy.com
  36. 36. OPEN PNEUMOTHORAX Large defects of the chest wall which remain open result in an open pneumothorax. If the opening in the chest wall is approximately two-thirds the diameter of the trachea, air passes preferentially through the chest defect with each respiratory effort. Effective ventilation is thereby impaired, leading to hypoxia www.indiandentalacademy.com
  37. 37. OPEN PNEUMOTHORAX Initial management is by promptly closing the defect with a sterile occlusive dressing large enough to overlap the wound's edges that is taped securely on three sides which provides a flutter - type valve effect. A chest drain should be placed remote from the site as soon as possible. Definitive surgical closure later. www.indiandentalacademy.com
  38. 38. TENSION PNEUMOTHORAX Tension pneumothorax develops when a one way valve air leak occurs either from the lung or through the chest wall. Air is forced into the thoracic cavity, between the parietal and visceral pleura, without any means of escape, completely collapsing the affected lung. www.indiandentalacademy.com
  39. 39. TENSION PNEUMOTHORAX Chest pain Air hunger Respiratory distress Tachycardia Hypotension Tracheal deviation Unilateral absence of breath sounds Neck vein distention and Cyanosis - late manifestation. www.indiandentalacademy.com
  40. 40. TENSION PNEUMOTHORAX It requires immediate decompression by inserting a large bore needle into the second intercostal space in the midclavicular line of the affected hemithorax. Definitive treatment requires the insertion of a chest drain into the fifth intercostal space (nipple level) between the anterior and midaxillary lines www.indiandentalacademy.com
  41. 41. MASSIVE HEMOTHORAX This results from a rapid accumulation of more than 1500 ml blood in the chest cavity. It is most commonly caused by a penetrating wound that disrupts the systemic or hilar vessels but can also result from blunt trauma. lt is discovered when shock is associated with the absence of breath sounds and/or dullness to percussion on one side of the chest. It is initially managed by a simultaneous restoration of blood volume and decompression of the chest cavity. www.indiandentalacademy.com
  42. 42. CARDIAC TAMPONADE Cardiac tamponade results commonly from penetrating injuries, but blunt injury may also cause the pericardium to fill with blood from the heart, great vessels or pericardial vessels. Pericardiocentesis, may result in immediate improvement. Definitive treatment - pericardiotomy www.indiandentalacademy.com
  43. 43. CIRCULATION WITH HEMORRHAGE CONTROL Shock is defined as an abnormality of the circulation that results in inadequate organ perfusion and tissue oxygenation. If unchecked this will lead to end organ dysfunction. Hemorrhage is the main cause of post injury deaths that are preventable by rapid treatment in the hospital setting. Hypotension following injury must be considered to be hypovolemic in origin until proved otherwise. www.indiandentalacademy.com
  44. 44. Classification and signs of hypovolemic shock (in an adult assuming a 70 kg patient with normally 5 litres of circulating volume) www.indiandentalacademy.com
  45. 45. HEMORRHAGE Hemorrhage is an acute loss of circulating blood volume. After airway and breathing, the initial treatment of shock is directed toward restoring cellular and organ perfusion with adequately oxygenated blood. www.indiandentalacademy.com
  46. 46. MANAGEMENT OF HEMORRHAGE The priority is to control the source of hemorrhage. External hemorrhage - controlled by direct manual pressure. Occult hemorrhage - immediate surgical intervention. www.indiandentalacademy.com
  47. 47. FLUID REPLACEMENT The aim of fluid management in hypotensive resuscitation - restore critical organ perfusion. Therefore in a standard adult trauma victim, 2 litres of warmed crystalloid, preferably Ringer's lactate, should be given and then the patient reassessed. In reassessing the circulatory state, one of three responses are seen :- Responder, Transient responder and non responder www.indiandentalacademy.com
  48. 48. BLOOD REPLACEMENT Either whole blood or packed cells can he used to resuscitate the trauma patient. The main purpose in transfusing blood is to restore the oxygen-carrying capacity of the intravascular volume. Volume resuscitation itself can be accomplished with crystalloids. www.indiandentalacademy.com
  49. 49. DISABILITY (NEUROLOGICAL EVALUATION) A rapid evaluation is performed at the end of the primary survey and this establishes the level of the patient's consciousness, as well as pupillary size and reaction. The Glasgow Coma Scale (GCS) is a detailed, quick, simple and predictive of patient outcome. www.indiandentalacademy.com
  50. 50. GLASGOW COMA SCALE www.indiandentalacademy.com
  51. 51. Exposure and environment The patient should be completely undressed to facilitate a thorough examination and assessment. After the assessment is completed it is important to cover the patient with warm blankets or an external warming device to prevent hypothermia. Intravenous fluids should be warmed before infusion. www.indiandentalacademy.com
  52. 52. Secondary survey This does not begin until the primary survey has been completed and the patient stabilized. It is a head to toe and front to back evaluation of the trauma patient. A thorough history and physical examination, including a reassessment of all vital signs, are carried out and each region of the body is completely examined. www.indiandentalacademy.com
  53. 53. HISTORY A through history should be taken from the patient and family. Allergies Medications currently used Past illness Pregnancy Last meal Events/ environment relating to injury www.indiandentalacademy.com
  54. 54. PHYSICAL EXAMINATION Head Neck Spinal cord Chest Abdomen Musculoskeletal www.indiandentalacademy.com
  55. 55. DIAGNOSIS OF MAXILLOFACIAL INJURIES Inspection Palpation Diagnostic Imaging www.indiandentalacademy.com
  56. 56. INSPECTION Hemorrhage Otorrhea Rhinorrhea Contour deformity Ecchymosis Edema Continuity defects Malocclusion www.indiandentalacademy.com
  57. 57. SCALP AND SKULL Examination should commence with an inspection of the scalp for contusions and lacerations concealed by the hair; particular attention should be paid to the back of the head where such injuries may be overlooked. www.indiandentalacademy.com
  58. 58. www.indiandentalacademy.com
  59. 59. EARS The external auditory meati should be inspected for discharges of blood and CSF. www.indiandentalacademy.com
  60. 60. ORBIT EVALUATION Periorbital edema and ecchymosis Gross visual acuity Diplopia Pupillary size and shape Subconjunctival hemorhage Pupillary level on both the sides Attachment of medial canthal tendon www.indiandentalacademy.com
  61. 61. NOSE www.indiandentalacademy.com
  62. 62. CSF RHINORRHEA www.indiandentalacademy.com
  63. 63. NOE FRACTURES  Nasal fracture comminuted with post. disp. widened nasal bridge splaying of nasal complex  Epistaxis  Severe periorbital edema  Subconjunctival hemorrhage  Traumatic telecanthus www.indiandentalacademy.com
  64. 64. MID FACE FRACTURE Inspection of the face in a typical b/l fracture of the maxilla Bilateral circumorbital ecchymosis Gross bilateral edema Lengthening of the middle third of the face. www.indiandentalacademy.com
  65. 65. www.indiandentalacademy.com
  66. 66. MAXILLARY MOBILITY www.indiandentalacademy.com
  67. 67. PERCUSSION www.indiandentalacademy.com
  68. 68. TESTING FOR SENSATION www.indiandentalacademy.com
  69. 69. PALPATION OF SUPRAORBITAL RIDGE & FZ REGION www.indiandentalacademy.com
  70. 70. ZYGOMATIC BONE AND ARCH INFRAORBITAL RIDGE www.indiandentalacademy.com
  71. 71. MANDIBLE www.indiandentalacademy.com
  72. 72. TEMPOROMANDIBULAR JOINT www.indiandentalacademy.com
  73. 73. COMPRESSION TEST www.indiandentalacademy.com
  74. 74. INTRAORAL www.indiandentalacademy.com
  75. 75. Guerin’s sign www.indiandentalacademy.com
  76. 76. FURTHER MANAGEMENT www.indiandentalacademy.com
  77. 77. GOD GAVE YOU EARS, EYES AND HANDS; USE THEM ON THE PATIENT IN THAT ORDER. Sir William Kelsey Fry www.indiandentalacademy.com
  78. 78. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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