2. Emergency management is the
creation of plans through which
casualties reduce vulnerability to
hazards and cope with disasters.
2
3. 3
Maxillofacial injuries
Maxillofacial injuries are commonly encountered in
the practice of emergency medicine. More than 50%
of patients with these injuries have multisystem
trauma that requires coordinated management
between emergency physicians and surgical
specialists in oral and maxillofacial surgery,
otolaryngology, plastic surgery, ophthalmology, and
trauma surgery
4. 4
Causes Of Maxillofacial Injuries
Due to direct violence
Interpersonal fights
Blow due to stick, metal rods, bricks etc
Fall
Road traffic accidents
Athletic injuries, Industrial mishaps
Iatrogenic – During dental treatment, fracture of a
tooth, maxillary tuberosity, fracture of mandible.
Indirect Violence
High velocity missiles
5. 5
Organization of trauma services
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
triage decisions are crucial in
determining individual patients survival
6. Road traffic accidents are the commonest cause of death
amongst young people- 15 to 29 years old
9. 9
Phases of Management in
Maxillofacial Injuries
Emergency or
initial care
Early care
Definitive care
Secondary care or
revision
10. 10
Peaks of mortality
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
12. Who is the angel ….the one who comes
first to rescue………
12
13. 13
Assessment of traumatized patient
This should not concentrate on the
most obvious injury but involve a rapid
survey of the vital function to allow
management priorities
5% of all deaths world wide are caused by trauma
This might be much higher in this country
14. 14
Primary survey
Ⓐ 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
15. 15
Airway
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
16. 16
Immediate treatment of airway obstruction in facial injured
patient
△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 oropharynx.
△ Controlling the tongue position in case of symphysial 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.
17. 17
Additional methods in preservation of the airway in
patient with severe facial injuries
Control of hemorrhage and Soft tissue laceration
Endotracheal intubation
Tracheostomy
Circothyroidectomy
22. 22
CIRCULATION
Circulatory collapse leads to low blood pressure,
increasing pulse rate and diminished capillary filling at
the periphery
Patient resuscitation
Restoration of cardio-respiratory function
Shock management
Replacement of lost fluid
24. 24
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
25. 25
EXPOSURE
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 .
26. 26
SECONDARY SURVEY
Although maxillofacial injuries is part of the
secondary survey, OMFS might be involved at early
stage if the airway is compromised by direct facial
trauma
Head injury
Abdominal injury
Injury to extremities
27. 27
Signs and symptoms of head injury
Loss of conscious
OR
History of loss of conscious
Memory loss
History of vomiting
Change in pulse rate, blood pressure and pupil reaction to light in
association with increased intracranial pressure
28. 28
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
29. 29
Hemorrhage
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)
30. 30
Neurologic Evaluation In Trauma With Head Injury
“Glasgow Coma Scale” by Jennet & Teasdale
Eye opening (E) Best verbal response (V)
4 – Open eyes spontaneously 5 – Appropriate & oriented
3 – Open eyes to voice 4 – Confused conversation
2 – Open eyes to pain 3 – Inappropriate words
1 – No eye opening 2 – Incomprehensible sounds
Best motor response (M) 1 – No sounds
6 – Obeys command
5 – Localizes to pain Sum : 3 - 15
4 – Withdraws to pain Severe head injury : 3 - 8
3 – Abnormal flexor response Moderate head inj. : 9 - 12
2 – Abnormal extensor response Mild head injury : 13 - 15
1 – No movement
39. 39
Treatment depends on fracture site and amount of segment
displacement
Closed reduction
Application of arch bars
Placement into intermaxillary fixation (IMF)
Open Reduction
Internal wire fixation
Bone plates
Lag screws
44. 44
Midface Fractures
LeFort I - Transverse Maxillary
Lefort II – Pyramidal
Lefort III - Craniofacial Dysjunction
Zygomatic Complex
Orbital Floor
Nasal Fractures
Naso-orbital/Ethmoid
45. 45
Le Fort Classification
Weakest areas of midfacial complex
when assaulted from a frontal direction
at different levels (Rene’ Lefort, 1901)
Lefort I: above the level of teeth
Lefort II: at level of nasal bones
Lefort III: at orbital level
48. 48
Facial Examination
Evaluate for laceration
Obvious depression in skull
Asymmetry
Discharge from nose or ear
Assume CSF leak
Palpation to note bone discontinuity
Bimanually in systematic manner
49. 49
Facial Examination
Evaluate mandibular opening
Palpation of buccal vestibul
Crepitus of lateral antral wall
Occlusion evaluated
Absence and quality of dentition
noted
Ecchymosis common finding
50. 50
Facial Examination
Orbits evaluated
Lid lacerations
Attachment of medial canthal
tendon
Rounding of lacrimal lake
Increased intercanthal
distance
Epiphora
Prompt Ophthalmology consult
55. 55
Nasal Fractures
Rule out septal hematoma
Remove clots with suction,
incise and drain if present to
prevent septal necrosis
Closed reduction for simple
fractures
Open reduction for severely
displaced fractures
60. Safety Measures
Intoxicated driving
Statistics reveal that the incidences of
road traffic accidents increases
exponentially when under the
influence of alcohol.
62. SEAT BELTS..!!
More than 50% of the accidents have been
proven to be caused in the absence of seat
belts and under the influence of alcohol.
Blood alcohol levels were seen to be over 100
mg/dl.
A study done in Philadelphia, USA in 1994 on
461 patients over 15 months shows
• Facial
injuries
51%
• Not wearing
seat belts
82%
• Positive for
alcohol
51%
