2. management of maxillofacial trauma 1

Management of
traumatized patient
1
12/28/2020Dr.Simon Rock

△ Road traffic accident (RTA)
35-60%
Rowe and Killey 1968;
Vincent-Towned and Shepherd 1994
△ Fight and assault (interpersonal violence)
Most in economically prosperous countries
Beek and Merkx 1999
△ Sport and athletic injuries
△ Industrial accidents
△ Domestic injuries and falls

Literatures reported different incidence in
different parts of the WORLD and at different
TIMES
√ 11% in RTA (Oikarinen and Lindqvist 1975)
 Mandible (61%)
 Maxilla (46%)
 Zygoma (27%)
 Nasal (19.5%)

 Geography
Fight, gunshot and RTA in developed and developing countries
respectively (Papavassiliou 1990, Champion et al 1997)
 Social factors
Violence in urban states (Telfer et al 1991; Hussain et al 1994;
Simpson & McLean 1995)
 Alcohol and drugs
Yong men involved in RTA wile they are under alcohol or drug effects
(Shepherd 1994)
 Road traffic legislation
Seat belts have resulted in dramatic decrease in injury (Thomas
1990, as reflected in reduction in facial injury (Sabey et al 1977)
 Season
Seasonal variation in temperature zones (summer and snow and ice
in midwinter) of RTA, violence and sporting injuries (Hill et al 1998)

This should not concentrate on the most obvious injury
but involve a rapid survey of the vital function to allow
management priorities
5
5% of all deaths world wide are caused by trauma
This might be much higher in this country 12/28/2020Dr.Simon Rock

First peak
Occurs within seconds of injury as a result of irreversible brain or
major vascular damage
Second peak
Occurs between a few minutes after injury and about one hour later
(golden hour)
Third peak
Occurs some days or weeks after injury as a result of multi-organ
failure 612/28/2020Dr.Simon Rock

 Pre-hospital care (field triage)
Care delivered by fully trained paramedic in maintaining airway,
controlling cervical spine, securing intravenous and initiating fluid
resuscitation
 Hospital care (inter-hospital triage)
Senior medical staff organized team to ensure that medical
resources are deployed to maximum overall benefit
 Mass casualty triage
7
triage decisions are crucial in
determining individual patients survival

Ⓐ Airway maintenance with cervical spine
control
Ⓑ Breathing and ventilation
Ⓒ Circulation with hemorrhage control
Ⓓ Disability assessment of neurological status
Ⓔ Exposure and complete examination of the
patient

Satisfactory airway signifies the implication of
breathing and ventilation and cerebral function
Management of maxillofacial trauma is an
integral part in securing an unobstructed
airway
Immobilization in a natural position by a semi-
rigid collar until damaged spine is excluded

10
Is the patient fully conscious? And able to maintain
adequate airway?
Semiconscious or unconscious patient rapidly suffocate
because of inability to cough and adopt a posture that
held tongue forward
Obstruction of airway
asphyxia
Cerebral hypoxia
Brain damage/ death

△Clearing of blood clot and mucous of the mouth and nares and
head position that lead to escape of secretions (sit-up or side
position)
△ Removal of foreign bodies as a broken denture or avulsed teeth
which can be inhaled and ensuring the patency of the mouth and
oropharynex
△ Controlling the tongue position in case of symphesial bilateral
fracture of mandible and when voluntary control of intrinsic
musculature is lost
△ Maintaining airway using artificial airway in unconscious
patient with maxillary fracture or by nasophryngeal tube with
periodic aspiration
△ Lubrication of patient’s lips and continuous supervision

Endotracheal intubation
Needed with multiple injuries, extensive soft tissue destruction and
for serious injury that require artificial ventilation
Tracheostomy
Surgical establishment of an opening into the trachea
Indications: 1. when prolonged artificial ventilation is necessary
2. to facilitate anesthesia for surgical repair in certain cases
3. to ensure a safe postoperative recovery after extensive surgery
4. following obstruction of the airway from laryngeal edema
5. in case of serious hemorrhage in the airway
Circothyroidectomy
An old technique associated with the risk of subglottic stenosis
development particularly in children. The use of percutaneous
dilational treachestomy (PDT) in MFS is advocated by Ward Booth et
al (1989) but it can be replaced with PDT.
Control of hemorrhage and Soft tissue laceration
Repair, ligation, reduction of fracture and Postnasal pack 1212/28/2020Dr.Simon Rock

Can be deadly if it involved the odontoid
process of the axis bone of the axis vertebra
If the injury above the clavicle bone, clavicle
collar should minimize the risk of any
deterioration

 Chest injuries:
Pneumothorax, haemopneumothorax, flail segments,
reputure daiphram, cardiac tamponade
signs
14
Clinical
Deviated trachea
Absence of breath
sounds
Dullness to percussion
Paradoxical movements
Hyper-response with
a large pneumothorax
Muffled heart sounds
Radiographical
Loss of lung marking
Deviation of trachea
Raised hemi-diaphragm
Fluid levels
Fracture of ribs

Occluding of open chest wounds
Endotreacheal intubation for unstable flail chest
Intermittent positive pressure ventilation
Needle decompression of the pericardium
Decompression of gastric dilation and aspiration of
stomach content

Circulatory collapse leads to low blood
pressure, increasing pulse rate and
diminished capillary filling at the periphery
16
Patient resuscitation
Restoration of cardio-respiratory function
Shock management
Replacement of lost fluid

17
 Fluid for resuscitation:
☞Adequate venous access at two points
☞ Hypotension assumed to be due to hypovolaemia
☞ Resuscitation fluid can be crystalloid, colloid or blood;
ringer lactate
☞ Surgical shock requires blood transfusion, preferably
with cross matching or group O+
☞ Urine output must be monitored as an indicator of
cardiac out put

18
Reduction and fixation will often arrest bleeding of long duration
Pulse and blood pressure should be monitored and appropriate
replacement therapy is to be started

Rapid assessment of neurological disability is made by noting the patient
response on four points scale:
A Response appropriately, is Aware
V Response to verbal stimuli
P Response to painful stimuli
U Does not responds, Unconscious

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
20
Score 8 or less indicates poor prognosis, moderate head injury
between 9-12 and mild refereed to 13-15 12/28/2020Dr.Simon Rock

All trauma patient must be fully exposed in a
warm environment to disclose any other hidden
injuries
When the airway is adequately secured the
second survey of the whole body is to be carried
out for:
Accurate diagnosis
Maintenance of a stable state
Determination of priorities in treatment
Appropriate specialist referral

 Head injury
 Abdominal injury
 Injury to extremities

 Open
 Closed
it is ranged from Mild concussion to brain death

Loss of conscious
OR
History of loss of conscious
History of vomiting
Change in pulse rate, blood pressure and pupil reaction to
light in association with increased intracranial pressure
Assessment of head injury (behavioral responses “motor and
verbal responses” and eye opening)
Skull fracture
Skull base fracture (battle’s sign)
Temporal/ frontal bone fracture
Naso-orbital ethmoidal fracture

25
slow reaction and fixation of dilated pupil denotes a rise in intra-
cranial pressure
Rise in intercranial pressure as a result of acute
subdural or extradural hemorrhage deteriorate
the patient’s neurological status
Apparently stable patient with suspicion of head injury
must be monitored at intervals up to one hour for 24 hour
after the trauma

Acute bleeding may lead to hemorrhagic shock and
circulatory collapse
Abdominal and pelvis injury; liver and
internal organs injury (peritonism)
Fracture of the extremities (femur)

In addition to direct injuries, loss of circulating
blood into peritoneal cavity or retroperitonial
space is life threatening, indicated by physical
signs and palpation, percussion and
auscultation
Management:
Diagnostic peritoneal lavage (DPL) to detect
blood, bowel content, urine
Emergency laprotomy

Fracture of extremities in particular the
femur can be a significant cause of occult
blood loss. Straightening and reduction of
gross deformity is part of circulation control
Cardinal features of extremities injury
Impaired distal perfusion (risk of ischemia)
Compartment syndrome (limb loss)
Traumatic amputation

△ emergency cases require instant admission
△ conditions that may progress to emergency
△ cases with no urgency

Soft tissue laceration (8 hours of injury with no delay
beyond 24 hours)
Support of the bone fragments
Injury to the eye
As a result of trauma, 1.6 million are blind, 2.3 million are
suffering serious bilateral visual impairment and 19 million with
unilateral loss of sight (Macewen 1999)
Ocular damage
Reduction in visual acuity
Eyelid injury

Diagnosis:
Laboratory investigation, CT and MRI scan
Management:
Dressing of external wounds
Closure of open wounds
Reposition and immobilization of the fractures
Repair of the dura matter
Antibacterial prophylaxis (as part of the general management
(Eljamal, 1993)

Management:
☞ Non-steroidal anti-inflammatory drugs can be prescribed
(Diclofenac acid)
☞ Reduction of fracture
☞ sedation

Necessary medications
Diet (fluid, semi-fluid and solid food) intake
and output (fluid balance chart)
Hygiene and physiotherapy
Proper timing for surgical intervention

2. management of maxillofacial trauma 1

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