Emergency Treatment of Maxillofacial Trauma
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Presented in 2014 at Khyber College of Dentistry Peshawar, Pakistan. Reference: Contemporary Oral and Maxillofacial Surgery 6th Edition
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Emergency Treatment of Maxillofacial Trauma
- 3. • Maxillofacialfracturesresultfromeitherbluntor penetratingtrauma. • Penetratinginjuriesaremorecommonincityhospitals. (MidfacialandZygomaticinjuries) • Bluntinjuriesaremorefrequentlyseenincommunity hospitals. (Noseandmandibularinjuries)
- 5. • Roadtrafficaccident(RTA)35-60% • Fightandassault(interpersonalviolence) • Sportandathleticinjuries • 60%ofpatientswithseverefacialtraumahavemultisystem traumaandthepotentialforairwaycompromise. –20-50%concurrentbraininjury. –1-4%cervicalspineinjuries. –Blindnessoccursin0.5-3%
- 7. Anatomy
- 8. Anatomy
- 9. Thisshouldnotconcentrateonthemost obviousinjurybutinvolvearapidsurvey ofthevitalfunctiontoallow managementpriorities 5% of all deaths world wide are caused by trauma
- 10. Ⓐ Airwaymaintenancewithcervicalspinecontrol Ⓑ Breathingandventilation Ⓒ Circulationwithhemorrhagecontrol Ⓓ Disabilityassessmentofneurologicalstatus Ⓔ Exposureandcompleteexaminationofthepatient
- 11. • Satisfactoryairwaysignifiestheimplicationofbreathingand ventilationandcerebralfunction • Managementofmaxillofacialtraumaisanintegralpartin securinganunobstructedairway • Immobilizationinanaturalpositionbyasemi-rigidcollaruntil damagedspineisexcluded
- 12. Isthepatientfullyconscious?Andabletomaintainadequateairway? Semiconsciousorunconsciouspatientrapidlysuffocatebecauseofinabilitytocough andadoptaposturethatheldtongueforward SEQUELOFFACIALINJURY Obstruction of airway asphyxia Cerebral hypoxia Brain damage/ death
- 13. • Clearingofbloodclotandmucousofthemouthandnaresandheadpositionthat leadtoescapeofsecretions(sit-uporsideposition) • Removal of foreign bodies as a broken denture or avulsed teeth which can be inhaledandensuringthepatencyofthemouthandoropharynx • Controllingthetonguepositionincaseofsymphesialbilateralfractureofmandible andwhenvoluntarycontrolofintrinsicmusculatureislost • Maintainingairwayusingartificialairwayinunconsciouspatientwithmaxillary fractureorbynasophryngealtubewithperiodicaspiration • Lubricationofpatient’slipsandcontinuoussupervision
- 14. 14 Chest Injuries: Pneumothorax, haemopneumothorax, flail segments, ruptureddiaphragm,cardiactamponade • Signs: Clinical Deviated trachea Absence of breath sounds Dullness to percussion Paradoxical movements Hyper-response with a large pneumothorax Muffled heart sounds Radiographic Loss of lung marking Deviation of trachea Raised hemi-diaphragm Fluid levels Fracture of ribs
- 15. • Occludingofopenchestwounds • Endotrachealintubationforunstableflailchest • Intermittentpositivepressureventilation • Needledecompressionofthepericardium • Decompressionofgastricdilationandaspirationof stomachcontent
- 16. Circulatorycollapseleadstolowbloodpressure, increasingpulserateanddiminishedcapillaryfillingat theperiphery •Patientresuscitation • Restorationofcardio-respiratoryfunction • Shockmanagement • Replacementoflostfluid
- 17. Rapidassessmentofneurologicaldisabilityismadebynotingthe patientresponseonfourpointsscale: • A Responseappropriately,is Aware • V Responsetoverbalstimuli • P Responsetopainfulstimuli • U Doesnotresponds,Unconscious
- 18. Glasgowcomascale(GCS) Eye opening Motor response Verbal response Spontaneous 4 Move to command 6 Converse 5 To speech 3 Localizes to pain 5 Confused 4 To pain 2 Withdraw from pain 4 Gibberish 3 none 1 flexes 3 grunts 2 Extends 2 none 1 none 1 Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15
- 23. Major • Lefort I,II,III(46%) • Mandibular(61%) Minor • Nasal(19.5%) • Sinuswall • Zygomatic(27%) • Orbitalfloor • Antralwall • Alveolarridge
- 24. • Highenergyinjuries. • Impact100timestheforceofgravityisrequired. • Patientsoftenhavesignificantmultisystemtrauma. • ClassifiedasLeFortfractures.
- 30. • RadiographicImaging: –Fractureinvolves: •Nasalbones •Medialorbit •Maxillarysinus •Frontal processofthe maxilla • CTofthefaceandhead
- 31. • Definition: –Fracturesthrough: • Maxilla • Zygoma • Nasalbones • Ethmoidbones • Baseoftheskull LeFortIII
- 34. • SecureanAirway • ControlBleeding • Headelevation40-60degrees • Consultwithmaxillofacialsurgeon • Considerantibiotics • Admission
- 35. •Pathophysiology • Mandibularfracturesarethethirdmost commonfacialfracture. • Assaultsandfallsonthechinaccountfor mostoftheinjuries. • Multiplefracturesareseeningreater then50%. • Associated C-spineinjuries–0.2-6%.
- 36. ClinicalFindings: • Mandibularpain. • Malocclusionoftheteeth • Separationofteethwith intraoralbleeding • Inabilitytofullyopenmouth. • Preauricularpainwithbiting. • Positivetonguebladetest.
- 38. • NondisplacedFractures: –Analgesics –Softdiet –Oralsurgeryreferralin1-2days • DisplacedFractures,OpenFracturesandFractureswith associatedDentalTrauma: –Urgentoralsurgeryconsultation • Allfracturesshouldbetreatedwithantibioticsandtetanusprophylaxis.
- 40. • Themandiblecanbedislocated: –Anterior 70% –Posterior(rare) –Lateral –Superior • Dislocationsaremostly bilateral.
- 43. • Musclerelaxant • Analgesic • Closedreductionintheemergencyroom • OralSurgeonConsultation: • Opendislocations • Superior,posteriororlateraldislocations • Non-reducibledislocations • Dislocationsassociatedwithfractures
- 44. •Disposition: • Avoidexcessivemouthopening • Softdiet • Analgesics • Oralsurgeryfollowup
- 45. • AssessABC'sfirst • Docompleteexamaspartofsecondarysurvey • ObtainstandardX-raysand/orCTscanasindicated • Decideifspecialistreferraland/oroperativerepair indicated • Arrangefollowupafterrepairtoassessfordelayed complicationsorcosmeticproblems