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Face Eye Trauma


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Face Eye Trauma

  1. 1. Maxillofacial, Ophthalmic & Dental Trauma
  2. 2. Morbidity & Mortality <ul><li>Mortality </li></ul><ul><ul><li>Primarily associated with brain and spine injury </li></ul></ul><ul><ul><li>Severe Facial fractures may interfere with airway and breathing </li></ul></ul><ul><li>Morbidity </li></ul><ul><ul><li>Disability concerns </li></ul></ul><ul><ul><li>Cosmetic concerns </li></ul></ul>
  3. 3. Maxillofacial Trauma <ul><li>Causes </li></ul><ul><ul><li>MVC, home accidents, athletic injuries, animal bites, violence, industrial accidents </li></ul></ul><ul><li>Soft tissue </li></ul><ul><ul><li>lacerations, abrasions, avulsions </li></ul></ul><ul><ul><li>vascular area supplied by internal and external carotids </li></ul></ul><ul><li>Management - </li></ul><ul><ul><li>Seldom life-threatening unless in the airway </li></ul></ul><ul><ul><li>consider spinal precautions </li></ul></ul><ul><ul><li>have suction available and in control of conscious patients </li></ul></ul><ul><ul><li>control bleeding </li></ul></ul>
  4. 4. Anatomy & Physiology Review <ul><li>Arteries </li></ul><ul><ul><li>temporal artery </li></ul></ul><ul><ul><li>mandibular artery </li></ul></ul><ul><ul><li>maxillary artery </li></ul></ul><ul><li>Nerves </li></ul><ul><ul><li>trigeminal (cranial nerve V) </li></ul></ul><ul><ul><li>facial (cranial nerve VII) </li></ul></ul>
  5. 5. Anatomy & Physiology Review <ul><li>Bones </li></ul><ul><ul><li>nasal </li></ul></ul><ul><ul><li>zygoma / zygomatic arch </li></ul></ul><ul><ul><li>maxilla </li></ul></ul><ul><ul><li>mandible </li></ul></ul>
  6. 6. Facial Fractures <ul><li>Fx to the mandible, maxilla, nasal bones, zygoma & rarely the frontal bone </li></ul><ul><li>S/S - </li></ul><ul><ul><li>pain, swelling, deep lacerations, limited ocular movement, facial asymmetry, crepitus, deviated nasal septum, bleeding, depression on palpation, malocclusion, blurred vision, diplopia, broken or missing teeth </li></ul></ul>
  7. 7. Facial Fractures <ul><li>Mandibular Fx - </li></ul><ul><ul><li>numbness, inability to open or close the mouth, excessive salivation, malocclusion </li></ul></ul><ul><li>Anterior dislocation </li></ul><ul><ul><li>may be caused by extensive dental work, yawning </li></ul></ul><ul><ul><li>Condylar heads move forward and muscles spasm </li></ul></ul>
  8. 8. LeFort Fractures <ul><li>Specially named facial fractures </li></ul><ul><li>Usually requires significant forces especially for LeFort II and III </li></ul><ul><ul><li>LeFort I - Maxillary fracture with “free-floating” maxilla </li></ul></ul><ul><ul><li>LeFort II - Maxilla, zygoma, floor of orbit and nose </li></ul></ul><ul><ul><li>LeFort III - Lower 2/3 of the face </li></ul></ul>
  9. 9. LeFort Fractures I II III
  10. 10. Signs and Symptoms <ul><li>Often associated with orbital fractures </li></ul><ul><ul><li>risk of serious airway compromise (bleeding & edema) </li></ul></ul><ul><ul><li>contraindication to NG tube or nasotracheal intubation </li></ul></ul><ul><li>Present with: </li></ul><ul><ul><li>Edema, Epistaxis, Numb upper teeth </li></ul></ul><ul><ul><li>Unstable maxilla, CSF rhinorrhea </li></ul></ul><ul><ul><li>Unusual facial appearance </li></ul></ul><ul><ul><ul><li>“ donkey face” (lengthening) </li></ul></ul></ul><ul><ul><ul><li>“ pumpkin face” (edema) </li></ul></ul></ul><ul><ul><ul><li>nasal flattening </li></ul></ul></ul>
  11. 11. Management <ul><li>Spinal motion restriction </li></ul><ul><li>Airway is the most difficult and most critical priority </li></ul><ul><li>Consider Early Intubation </li></ul><ul><li>Surgical Airway may be the only alternative but NEVER the first consideration </li></ul><ul><li>Suction & Control Bleeding </li></ul><ul><li>Critical trauma patient - Transport accordingly </li></ul>
  12. 12. Facial Fractures <ul><li>Caution </li></ul><ul><ul><li>NG tube or Endotracheal tube placement may be HAZARDOUS!!! </li></ul></ul>
  13. 13. Ear Trauma <ul><li>External injuries </li></ul><ul><ul><li>lacerations, avulsions, amputations, frostbite </li></ul></ul><ul><ul><li>Control bleeding with direct pressure </li></ul></ul><ul><li>Internal injuries </li></ul><ul><ul><li>Spontaneous rupture of eardrum will usually heal spontaneously </li></ul></ul><ul><ul><li>penetrating objects should be stabilized, not removed! </li></ul></ul><ul><ul><ul><li>Removal may cause deafness or facial paralysis </li></ul></ul></ul><ul><ul><ul><li>Hearing loss may be result of otic nerve damage in basilar skull fracture </li></ul></ul></ul>
  14. 14. Anatomy & Physiology Review <ul><li>Ear </li></ul><ul><ul><li>Outer Ear (Pinna) </li></ul></ul><ul><ul><ul><li>Cartilage </li></ul></ul></ul><ul><ul><ul><li>little blood supply </li></ul></ul></ul><ul><ul><li>External Ear canal </li></ul></ul><ul><ul><ul><li>mucous membrane that secretes wax for protection </li></ul></ul></ul><ul><ul><li>Middle Ear </li></ul></ul><ul><ul><ul><li>separated from external canal by ear drum </li></ul></ul></ul><ul><ul><ul><li>delicate structure needed for hearing </li></ul></ul></ul>
  15. 15. Ear Injuries <ul><li>Separation of ear cartilage </li></ul><ul><ul><li>treat as an avulsion </li></ul></ul><ul><ul><li>dress and bandage </li></ul></ul><ul><ul><li>consider disability and cosmetic concerns </li></ul></ul><ul><li>Bleeding from ear canal </li></ul><ul><ul><li>cover with loose dressing only </li></ul></ul>
  16. 16. Barotitis <ul><li>Changes in pressure cause pressure buildup and/or rupture of tympanic membrane </li></ul><ul><li>Boyle’s Law, at constant temperature, the volume of gas is inversely proportionate to the pressure </li></ul><ul><li>s/s - pain, blocked feeling in ears, severe pain </li></ul><ul><li>equalize pressure by yawning, chewing, moving mandible, swallowing (open Eustachian tubes allowing gas to release) </li></ul>
  17. 17. Eye Anatomy <ul><li>Bony orbit </li></ul><ul><li>Eyelid </li></ul><ul><li>Lacrimal apparatus </li></ul><ul><li>Sclera </li></ul><ul><li>Cornea </li></ul><ul><li>Conjunctiva </li></ul><ul><li>Iris </li></ul><ul><li>Pupil </li></ul><ul><li>Lens </li></ul><ul><li>Retina </li></ul><ul><li>Optic nerve </li></ul>
  18. 18. Eye Injuries <ul><li>Penetrating </li></ul><ul><ul><li>Abrasions </li></ul></ul><ul><ul><li>Foreign bodies (deep, superficial, impaled) </li></ul></ul><ul><ul><li>Lacerations (deep or superficial, eyelid) </li></ul></ul><ul><li>Burns </li></ul><ul><ul><li>flash </li></ul></ul><ul><ul><li>acid/alkali </li></ul></ul><ul><li>Blunt </li></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Conjunctival hemorrhage </li></ul></ul><ul><ul><li>Hyphema </li></ul></ul><ul><ul><li>Ruptured globe </li></ul></ul><ul><ul><li>Blow-out fracture of orbit </li></ul></ul><ul><ul><li>Retinal detachment </li></ul></ul>
  19. 19. Blow-out Orbital Fracture <ul><li>Usually result of a direct blow to the eye </li></ul><ul><ul><li>S/S - flatness, numbness </li></ul></ul><ul><ul><li>epistaxis, altered vision </li></ul></ul><ul><ul><li>periorbital swelling </li></ul></ul><ul><ul><li>diplopia </li></ul></ul><ul><ul><li>inophthalmos </li></ul></ul><ul><ul><li>impaired ocular movement </li></ul></ul>
  20. 20. Foreign Bodies <ul><li>S/S - sensation of something in eye, excessive tearing, burning </li></ul><ul><li>Inspect inner surface of upper lid as well as sclera </li></ul><ul><li>Flush with copious normal saline away from opposite eye </li></ul>
  21. 21. Corneal Abrasion <ul><li>Caused by foreign body objects, eye rubbing, contact lenses </li></ul><ul><li>S/S - pain, feeling of something in eye, photophobia, tearing, decreased visual acuity </li></ul><ul><li>irrigate, patch both eyes </li></ul><ul><li>Usually heals in 24 to 48 hours if not infected or toxic from antibiotics </li></ul>
  22. 22. Other Globe Injuries <ul><li>Contusion, laceration, hyphema, globe or scleral rupture </li></ul><ul><li>S/S - Loss of visual acuity, blood in anterior chamber, dilation or constriction of pupil, pain, soft eye, pupil irregularity </li></ul><ul><li>Management </li></ul><ul><ul><li>Consider C-spine precautions due to forces required for injury </li></ul></ul><ul><ul><li>No pressure to globe for dressing, cover both eyes </li></ul></ul><ul><ul><li>Avoid activities that increase intra-ocular pressure </li></ul></ul>
  23. 23. Mouth Injuries <ul><li>Usually result from </li></ul><ul><ul><li>MVCs </li></ul></ul><ul><ul><li>Blunt injury to the mouth or chin </li></ul></ul><ul><ul><li>Penetrating injury due to GSW, lacerations, or punctures </li></ul></ul>
  24. 24. Anatomy & Physiology Review <ul><li>Muscles </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><li>Masseter muscles </li></ul></ul><ul><li>Nerves </li></ul><ul><ul><li>Hypoglossal </li></ul></ul><ul><ul><li>Glossopharyngeal </li></ul></ul><ul><ul><li>Trigeminal </li></ul></ul><ul><ul><li>Facial </li></ul></ul><ul><li>Bones </li></ul><ul><ul><li>Mandible </li></ul></ul><ul><ul><li>Maxilla </li></ul></ul><ul><ul><li>Hyoid </li></ul></ul><ul><ul><li>Palate </li></ul></ul><ul><li>Teeth </li></ul>
  25. 25. Mouth Injuries <ul><li>Primary concerns </li></ul><ul><ul><li>Airway compromise secondary to bleeding </li></ul></ul><ul><ul><li>FBAO secondary to broken or avulsed teeth </li></ul></ul><ul><ul><li>Impaled object </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>ABCs </li></ul></ul><ul><ul><ul><li>Suction prn </li></ul></ul></ul><ul><ul><li>Stabilize impaled object </li></ul></ul><ul><ul><li>Collect tissue: tongue or tooth </li></ul></ul>
  26. 26. Dental Trauma <ul><li>32 teeth in normal adult </li></ul><ul><li>Associated with facial fractures </li></ul><ul><li>May aspirate broken tooth </li></ul><ul><li>Avulsed teeth can be replaced so find them! </li></ul><ul><li>Early hospital notification to find dentist </li></ul><ul><li>< 15 minutes, may be asked to replace the tooth in socket </li></ul><ul><li>do not rinse or scrub (removes periodontal membrane and ligament) </li></ul><ul><li>preserve in fresh whole milk </li></ul><ul><li>Saline OK for less than 1 hour </li></ul>
  27. 27. Nasal Injuries <ul><li>Variety of mechanisms including blunt or penetrating trauma </li></ul><ul><li>Most common injury </li></ul><ul><ul><li>Adults - Epistaxis </li></ul></ul><ul><ul><li>Children - Foreign bodies </li></ul></ul>
  28. 28. Anatomy & Physiology Review <ul><li>Nasal bone </li></ul><ul><ul><li>between the eyes </li></ul></ul><ul><li>Nasal cartilage </li></ul><ul><ul><li>provides shape to nose </li></ul></ul><ul><li>Internal </li></ul><ul><ul><li>septum </li></ul></ul><ul><ul><li>turbinates </li></ul></ul><ul><ul><li>sinuses </li></ul></ul>
  29. 29. Nasal Injuries <ul><li>Epistaxis </li></ul><ul><ul><li>anterior bleeding from septum </li></ul></ul><ul><ul><ul><li>usually venous </li></ul></ul></ul><ul><ul><li>posterior bleeding </li></ul></ul><ul><ul><ul><li>often drains to airway </li></ul></ul></ul><ul><ul><li>may be associated with </li></ul></ul><ul><ul><ul><li>sphenoid and/or ethmoid fractures </li></ul></ul></ul><ul><ul><ul><li>basilar skull fracture </li></ul></ul></ul>
  30. 30. Nasal Injuries Often looks worse than it is! A little patience and direct pressure work wonders!
  31. 31. Nasal Injuries <ul><li>Foreign Bodies </li></ul><ul><ul><li>Variety of objects </li></ul></ul><ul><ul><ul><li>food </li></ul></ul></ul><ul><ul><ul><li>toys </li></ul></ul></ul><ul><ul><li>Often can be left alone and removed later </li></ul></ul>
  32. 32. Nasal Injury Management <ul><li>Epistaxis </li></ul><ul><ul><li>Direct pressure over septum </li></ul></ul><ul><ul><li>Upright position, leaning forward or in lateral recumbent position </li></ul></ul><ul><li>If CSF present, do not apply direct pressure </li></ul><ul><ul><li>allow to drain </li></ul></ul>
  33. 33. Neck Trauma <ul><li>Neck - 3 zones </li></ul><ul><ul><li>1 = sternal notch to top of clavicles (highest mortality) </li></ul></ul><ul><ul><li>2 = clavicles or cricoid cartilage to angle of the mandible (contains major vasculature and airway) </li></ul></ul><ul><ul><li>3 = above angle of mandible (distal carotid, salivary, pharynx) </li></ul></ul>
  34. 34. Neck Trauma <ul><li>Transected Trachea </li></ul><ul><ul><li>Larynx separated from trachea or fractured </li></ul></ul><ul><ul><ul><li>vocal cord swelling </li></ul></ul></ul><ul><ul><ul><li>altered airway landmarks </li></ul></ul></ul><ul><ul><ul><li>soft tissue edema </li></ul></ul></ul><ul><li>Vessel lacerated or torn </li></ul><ul><ul><li>severe bleeding (large vessels) </li></ul></ul><ul><ul><li>airway compromise </li></ul></ul><ul><ul><li>risk of air emboli, hypoxia, or ischemia </li></ul></ul>
  35. 35. Neck Trauma <ul><li>Signs & Symptoms </li></ul><ul><ul><li>pale or cyanotic face </li></ul></ul><ul><ul><li>obvious external injury </li></ul></ul><ul><ul><li>frothy blood or sputum from wound </li></ul></ul><ul><ul><li>SQ air </li></ul></ul><ul><ul><li>voice change </li></ul></ul><ul><ul><li>feeling of fullness in throat </li></ul></ul><ul><ul><li>Signs of stroke with air emboli </li></ul></ul>
  36. 36. Esophageal Injury <ul><li>Especially common in penetrating trauma </li></ul><ul><ul><li>S/S may include subcutaneous emphysema </li></ul></ul><ul><ul><li>neck hematoma, blood in the NG tube or posterior nasopharynx </li></ul></ul><ul><li>high mortality rate from mediastinal infection secondary to gastric reflux through the perforation </li></ul><ul><li>Consider Semi-fowler’s vs. supine position unless contraindicated by MOI. </li></ul>
  37. 37. Neck Trauma Management <ul><li>ABCs </li></ul><ul><ul><li>Suction </li></ul></ul><ul><ul><li>Intubate EARLY!!! </li></ul></ul><ul><ul><li>May require cricothyrotomy </li></ul></ul><ul><ul><li>stop bleeding as best as possible </li></ul></ul><ul><li>Occlude large blood vessel quickly </li></ul><ul><ul><li>Left lateral position with occlusive dressing to wound </li></ul></ul><ul><li>Consider spinal motion restriction </li></ul><ul><li>Stabilize impaled objects </li></ul><ul><li>Transport to trauma center </li></ul>
  38. 38. Cranial Nerve Hints <ul><ul><li>May not be helpful in unconscious patients, but if they happen to wake up: </li></ul></ul><ul><ul><li>Cranial nerve I - loss of smell, taste (basilar skull fracture hallmark) </li></ul></ul><ul><ul><li>Cranial nerve II - blindness, visual defects </li></ul></ul><ul><ul><li>Cranial nerve III - Ipsilateral, dilated fixed pupil </li></ul></ul><ul><ul><li>Cranial nerve VII - immediate or delayed facial paralysis (basilar skull or LeFort) </li></ul></ul><ul><ul><li>Cranial nerve VIII - deafness (basilar skull fx) </li></ul></ul>