This document provides information on assessing and managing patients presenting with acute maxillofacial trauma. It describes conducting a primary and secondary survey following the ABCDE protocol to address life threats and identify injuries. The primary survey involves assessing the airway, breathing, circulation, disability, and exposure. Key signs of injury for different facial structures are outlined. The document emphasizes the importance of thorough history taking and physical examination, including extraoral and intraoral inspection and palpation, to diagnose and manage maxillofacial trauma.

1. HP GDC SHIMLA
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
By – Dr. Abhijeet – Kamble
JR I
PHYSICAL ASSESSMENT OF A TRAUMA PATIENT
PRESSENTING WITH ACUTE INJURY
PARTICULARLY TO MAXILLOFACIAL REGION

2. CONTENTS :
 Introduction
 Primary survey
 Secondary survey
 History and physical examination
 Diagnostic Imaging
 General management of acute injuries

3. TRAUMA/INJURY:
 Facial trauma is one of the main reason of maxillofacial emergencies.
 Proportionally male are more prone to trauma than females ( 2:1 )
 FACIAL TRAUMA :
- It may result from
1. Interpersonal Violence 52%
2. RTA 16%
3. Sports injury 19 %
4 . Fall 11 %
5 . Industrial accidents 2%

4. AIM FOR TRAUMA MANAGEMENT :
 Identification of major trauma patient at the scene of the incident
 Immediate intervention for safe transport
 Rapid transfer to trauma center for surgical management and critical care
 Coordinated specialist reconstruction
 Targeted comprehensive rehabilitation.
-- TRIAGE –
- It is the sorting of patients based on their need for treatment and the available resources to
provide the treatment.
- Applicable for mass casuality.
** Rule of Thumb – Preference is given to those patients , who have possibility of good quality
survival with minimum resources.

6. TRIAGE CATEGORIZATION :
T1 : RED COLOR ( Immediate treatment need ) , these group of patients require
immediate intervention for survival .
Eg : Airway obstruction/External haemmorhage.
T2 : YELLOW COLOR ( Delayed treatment need ) these patients require *Airway
management , but delay is possible
Eg : Mandibular fracture
T3 : GREEN COLOR ( Minimum treatment needed ) these require only minimum
treatment
Eg : Suturing of soft tissue injuries
T4 : BLACK COLOR : Patients with multiple trauma and are addressed once T2,T1
Patients are managed.
T1 > T4 > T2 > T3

7. SEQUENCE OF MANAGEMENT :
Trauma :
Primary survey :> ABCDE defines
- The specific prioritized evaluation and intervention that should be followed in
all injured patients.
Secondary survey :
- After initial survey has been accomplished and the patient has been stabilized.
- Involves more time – consuming tests and observations , does not begin until
primary survey is completed

8. PRIMARY/INITIAL SURVEY : The initial evaluation of a patient
with facial trauma should follow a systematic approach. The assessment begins with
primary survey standard protocol for evaluating airway , breathing , circulation , central
nervous system status & cervical spine .
 ABCDE :
A : Airway & Cervical spine control
B : Breathing
C : Circulation & Heammorhage control
D : Disability limitation & Neuro Examination
E : Exposure , by undressing to look for other injuries.
-- AIRWAY & SPINE CONTROL –-
- Normal breathing : Nonstrenuous , non Exertional , Passive
, no noise & primarily by diaphragm.
- Abnormal breathing : strenuous , exertional , active & noisy
by – diaphragm + accessory muscles of respiration (
Intercoastal , supraclavicular )
** Activity of these , indicates “ Airway obstruction “

9. Noises :
1. Gurgling noise : Soft , low pitched & are due to secretions / laxed soft
tissues.
2. Stridor : Sharp & high pitched ** due to obstruction of ‘ upper airway & heartd
on “ Inspiration ‘
3. Weezing/Ronchi : Soft , low pitched ** heard on “ Expiration ‘ , due to lower
airway obstruction ( Asthma )
** In case of compromised airway – Maintain airway patency.
-- AIRWAY MANEUVERS –
1. Head tilt
2. Head tilt & chin lift
3. Chin lift
4. Jaw thrust

10. ** Head tilt , Head tilt & chin lift – are not safe in trauma patients as they move head.
** Jaw thrust is the safest in trauma cases.
* In Non trauma cases : Head tilt + chin lift is BEST’
Q : When to consider Cervical neck injury –
- - Injuries above clavicle.
** Best head Immobilizer :
- Purpousfully built head immobilizer >> board & binding >> rigid collars ( 50 % )
-- MECHANICAL AIRWAYS –-
1. OROPHRYNGEAL ( GLUEDAL ) AIRWAY :
- Oral to phynx
- Pushes tongue forwards & patient can breath along or through it.
INDICATIONS :
1. In emergency cases when time is not sufficient for “ NASOPHARYNGEAL AIRWAY “
2. Fracture of bones in & around nasal cavity.

11. C/I : Patients with intact gag reflex.
Size : Corner of mouth to lobule of ear/angle of mandible.
-- NASOPHARYNGEAL AIRWAY ( NASAL TRUMPET ) –
- Soft hollow tubes , Nose to Pharynges
- ** Requires Nasal preparation :
1. Cocaine ( LA + Vasoconstriction ) Shrinkage of nasal mucosa
2. Xylocaine jelly ( LA ) + Xylo/oxymetazoline ( Nasal decongestant ) Shrinkage of nasal
mucosa by vasoconstriction .
Size : Ala of nose to ear lobule/angle of mouth.
INDICATIONS : In patients with intact gag reflex.
C/I : 1. Emergency cases, with immediate requirement to establish airway
2. Fracture of bones in & around nose.
** Avoided : Inc ICP
- Fracture bones displaced further
- Intracranial placement ( Inc ICP , inc risk of meningitis , inc damage to brain tissues. )

12. EMERGENCY MANAGEMENT , INTUBATION
CONSIDERATIONS :
 Avoid nasotracheal intubation :
- Nasocranial intubation
- Nasal hemorrhage
Avoid Rapid Sequence Intubation :
- Failure to intubate or ventilate.
- Consider awake intubation
- Consider Fiberoptic intubation , if available
- Be prepared for Cricothyroidotomy.

13. EMERGENCY MANAGEMENT ,
HEMORRHAGE CONTROL -
 Maxillofacial bleeding :
- Direct pressure
- Avoid blind clamping in wounds.
- Nasal bleeding :
- Direct pressure
- Anterior & posterior packing
- Pharyngeal bleeding :
- Packing of the pharynx around ET Tube .

14. BREATHING & VENTILLATION :
if patients respiration rate/depth decreases , it requires Artificial
airway.
• Bag – Valve Mask ventilation
• Mouth – Mouth ventilation
• Mouth – Nose ventilation
• Mouth – Facemask – mouth
-- Bag-Valve Mask –
- Excessive pressure on angle of mandible , can compress * Marginal mandibular
branch.
-- Sellick’s maneuver ( Cricoid Pressure ) –
- Application of pressure with thumb & index finger on “ Cricoid cartilage “ to
obstruct esophagus to prevent flow of air in GI tract & regurgitation of solid
content.
Indicators of difficult face mask ventilation :
1. Age : older patients
2. H/O Snoring

15. 3. BMI > 26 Kg/m2 ** Obese patients
4. Heavy beard
5. Prognathic/retrognathic mandible
6. Absence of teeth.
NOTE : Dentulous patients are good cases ( Presence of teeth are not difficult
cases)
-- ENDOTRACHEAL INTUBATION –
1. Oro-tracheal
2. Naso-tracheal
-- DEFINATIVE AIRWAY –-
- Defined as cuffed tube, passed into trachea via , vocal routes with cuff
inflated
- 100 % definite airway , maintances breathing & ensures gaseous exchange &
prevents Aspiration.

16. Glassgow Coma Scale : by Jennet & Teasdale

17.  Others –
1. Trauma score : By – Champion & Associates
CNS : GCS
CVS : Systolic BP & Capillary refill time
RESPIRATORY RATE : RR & Chest expansion
2. Revised trauma score : Champion & Associates :
CNS : GCS
CVS : Systolic BP
RS : RR

18. CIRCULATION AND HAEMORRHAGE CONTROL
 Acute blood loss is one of the major causes of preventable deaths on arrival
at hospital .
 Acute blood loss resulting in hypovolemic shock is responsible for 30% to 40 %
of trauma deaths.
 SHOCK :
- Recognition of shock :
- Tachycardia
- Skin color
- Level of consciousness
- Respiratory rate
- Urine output.
-- INITIAL MANAGEMENT OF HAEMORRHAGIC SHOCK –
- Posterior nasal pack
- Packing using foley’s catheter

19. DISABILITY
 A rapid evaluation is performed at the end of the primary
survey, and this establishes the patient’s level of
consciousness.
 A : Alert
 V : responds to Vocal stimuli
 P : responds to Painful stimuli
 U : Unresponsive to all stimuli
 EXPOSURE & ENVIORNMENTAL CONTORLE –
-- SECONDARY SURVEY – Performed after the primary survey
issues have been addressed.
- It aims to identify and fully appreciate all other injuries
that the polytraumatized patient may have suffered that
might otherwise go unnoticed , particularly in the presence
of a reduced GSC score.

20. HISTORY – After the patient has been stabilized , as complete history as possible
should be obtained
 Obtain a history from the patient , witnesses and or EMS
 Specific Questions :
- Was there LOC? If so , how long?
- How is your vision ?
- Hearing problems ?
- Is there pain with eye movements?
- Are there areas of numbness or tingling on your face ?
- Is there pain with moving jaws ?
-- CLINICAL EXAMINATION –
- EXTRAORAL EXAMINATION –
- INSPECTION :
- Scalp
- Ear , Eyes , Nose
- Middle third of the face
- Lower third of face

21.  PALPATION :
 INTRAORAL EXAMINATION :
- Inspection
- Palpation
- Percussion & Auscultation
-- GENERAL EXAMINATION –
- Nervous system
- Orientation
- memory
- Respiratory system & CVS
- Chest & abdomen

22. EXTRAORAL EXAMINATION
 INSPECTION :
- FACE : Washed with warm saline/water
- Cleaning of dried blood clots/scabs
- Check for – presence of edema , ecchymosis , deformity , facial asymmetry.
- Bleeding areas , CSF leaks .
- Associated soft tissue injury .
- ESSENTIALS :
- Examination gloves
- Single use tongue blades
- Examination light
- Visual chart
- Nasal speculum ( In case of a nasal examination )

23. SCALP & SKULL
 Lacerations & contusions .
 Depressed fracture of skull .
** Battle’s sign :
- Ecchymosis near mastoid process
- EYE :
- Examine for broken glass piece/debris
- Lacerations
- Corneal abrasions & scleral tears
- Circumorbital Edema & Ecchymosis
** Examine for movements of the eye in all GAZES &
patency of optic & oculomotor nerve.

24.  Racoon eyes .
 Subconjunctival Ecchymosis –
- Flame shaped hemorrhage with posterior limit not seen .(
Suspect fracture of the orbital walls )
- GLOBE POSITION :
- Simple testing of pupil axis is provided using a straight
instruments .
- The examiner should include an exam from above & below to
evaluate facial symmetry .

25. -EAR :
-Lacerations of auricle , external auditory canal, tympanic membrane .
-Check for bleeding & foreign bodies
-Check for any CSF Ottorrhea
-Check for any Blood discharge
-Dislocated condylar neck may Fracture EAM
- Pupillary Reaction :
- A light is used to assess pupillary reaction.

26. BATTLES SIGN :
 Posterior Auricular Bruising
 Base of Skull Fracture
OR
- Condyle impacts above into MCF Fracturing the mastoid
process

27. FRONTO-NASOETHMOIDAL REGION :
NOE complex factures involve the medial vertical ( nasomaxillary ) buttresses of
the facial skeleton
 IN CASE OF FRACTURE IN NOE :
- Swelling & pain in the medial canthal area .
- Intercanthal distance :
- Nose :
- Uni/bilateral epistaxsis
- CSF rhinorrhea – tram line effect & halo effect
- Deviation , asymmetry of nose , septal hematoma
- The region is palpated for tenderness , deformity and crepitus .

28. CSF RHINNORHEA
 Leakage of CSF from nose due to fractured cribriform plates
of ethmoid bone generally with Le-Fort 2 & 3 fractures .
 Tram line effect
 Patient complaints of salty taste in throat
 Warn patient not to blow nose vigorously and raise head
** CSF LEAK ( Clinical sign : Straw-colored or clear nasal
discharge )
• Lab analysis for beta-transferrin
• BALLON FACIES : Circumorbital edema
• PANDA FACIES : Circumorbital ecchymosis

29. EXTRAORAL PALPATION -
 Fracture palpation :
- The midface & frontal cranium should be palpated to detect bony irregularities
step-offs , crepitus & sensory disturbances .
- Gentle but firm pressure.
- Depression over forehead.
- Areas of tenderness, step
deformity, abnormal mobility.
- SUPRA-ORBITAL RIM
- FRONTOZYGOMATIC SUTURE

30. Zygomatic buttress > Zygomatic arch > Infra orbital rim > Zygomaxillary suture
 Feel for STEP DEFORMITY in bone by palpating starting from :

31. Zygomatic Examination
 Unilateral epistaxis
 Depressed malar prominence
 Orbital rim step-off
 Altered relative pupil position
 Periorbital ecchymosis
 Subconjunctival hemorrhage

32. TMJ Palpation
MANDIBLE :
- Area of tenderness, step
deformity
- Abnormal mobility .
- Inferior border continuity .
- Angle of mandible.

33. Palpation of Nose :
 Bimanual palpation :
- Instrument is placed in nose & pushed laterally in medial canthal area to test
for instability & crepitation , which suggest an ** UNSTABLE NOE FRACTURE “

34.  Examination of the nose starts with inspection for swelling or asymmetry , followed by
palpation .
 Characteristics signs for nasal fracture are :
- Pain
- Bleeding
- Swelling
- Compromised nasal airway
- Crepitation
- Palpable bony dislocation

35. NECK EXAMINATION :
 Palpate posterior neck for
any sign of cervical spine
trauma
Anterior neck for sign of laryngeal trauma
If laryngeal fracture suspected , CT neck
recommend
Examine for any sign of penetrating neck
trauma or laceration.

36. INTRA ORAL EXAMINATION
 INSPECTION :
- Mouth opening
- Occlusion
- Lacerations
- Ecchymosis
 EXAMINATION OF PALATE :
- NOTE : ** Palatal hematoma
&/ or palatal lacerations can be
noted in a split palate.

37. Intraoral palpation :
 Buccal & lingual sulcus –
- Tenderness, alteration in contour ,
crepitus
- Mandible palpation
- Mobility of maxilla .

38.  Differentiating Leforts :
- Pull forward on maxillary teeth
1. Lefort I : maxilla only
2. Lefort II : maxilla & base of nose moves
3. Lefort III : whole face moves
 Mobility of midface may be tested by
grasping anterior alveolar arch &
pulling forward while stabilizing patient
with other hand .

39. AUSCULTATION :
 PERCUSSION :
- Percussion :
- Maxillary sinus ( CRACKED TEACUP
SOUND )

40. TESTS :
 Acuity testing
 Visual Field testing
 Testing of ocular mobility

41. Extra ocular muscle function testing

42. Forced Deduction test

43. Gross Digital intra ocular pressure
testing

44. REFERENCES :
 Essentials of Craniomaxillofacial trauma , Jeffery R.
Marcus
 Facial trauma , Seth R. Thaller
 Oral & Maxillofacial trauma , 4th Edition , Fonseca