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

PRIMARY ASSESSMENT AND
PREOPERATIVE MANAGEMENT OF
MAXILLOFACIL AND HEAD INJURIES
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION


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


TRIMODAL DISTRIBUTION OF DEATH


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.

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.

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.

CERVICAL SPINE
Assume injury to cervical spine if –
Blunt trauma above clavicles
Head injury
Maxillofacial trauma
Multiple trauma


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.


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.

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.

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.


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.

The fractured
nose may need
to be packed
as a result of
damage to the
anterior or
posterior
ethmoidal
vessels or the
maxillary
artery.

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.

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.

JAW THRUST
Jaw thrust is performed
by grasping the angles
of the mandible with
one hand on each side
and displacing the
mandible forward.


TONGUE STAY SUTURE


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.

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)

ALOGRITHM LEADING TO
SURGICAL AIRWAY


CRICOTHYRIODOTOMY


TRACHEOSTOMY


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.

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.

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.

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.


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.

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.

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


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.

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.

Chest pain
Air hunger
Respiratory distress
Tachycardia
Hypotension
Tracheal deviation
Unilateral absence of breath sounds
Neck vein distention and Cyanosis - late
manifestation.

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

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.

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

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.

Classification and signs of hypovolemic shock
(in an adult assuming a
70 kg patient with normally 5 litres of circulating volume)


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.


MANAGEMENT OF HEMORRHAGE
The priority is to control the source of
hemorrhage.
External hemorrhage - controlled by direct
manual pressure.
Occult hemorrhage - immediate surgical
intervention.

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

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.


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.

GLASGOW COMA SCALE


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.

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.

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

PHYSICAL EXAMINATION
Head
Neck
Spinal cord
Chest
Abdomen
Musculoskeletal


DIAGNOSIS OF MAXILLOFACIAL
INJURIES
Inspection
Palpation
Diagnostic Imaging


INSPECTION
Hemorrhage
Otorrhea
Rhinorrhea
Contour deformity
Ecchymosis
Edema
Continuity defects
Malocclusion

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.

EARS
The external
auditory meati
should be inspected
for discharges of
blood and CSF.


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

NOSE


CSF RHINORRHEA


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

 Epistaxis
 Severe periorbital edema
 Subconjunctival

hemorrhage
 Traumatic telecanthus


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.


MAXILLARY MOBILITY


PERCUSSION


TESTING FOR SENSATION


PALPATION OF SUPRAORBITAL RIDGE &
FZ REGION


ZYGOMATIC BONE AND ARCH
INFRAORBITAL RIDGE


MANDIBLE


TEMPOROMANDIBULAR JOINT


COMPRESSION TEST


INTRAORAL


Guerin’s sign


FURTHER MANAGEMENT


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


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

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