Maxillofacial trauma

Management of
traumatized patient
1

Causes:
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

Incidence
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%)

Factors affecting the high/low incidence of

maxillofacial trauma
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 al4
1998)

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

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 of6
multi-organ failure

Organization of trauma services

triage decisions are crucial in
determining individual patients survival

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

Primary survey
Airway maintenance with cervical
spine control
Breathing and ventilation
Circulation with hemorrhage control
Disability assessment of neurological
status
E xposure and complete examination
of the patient
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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
9

Sequel of facial injury

Obstruction of airway
asphyxia
Cerebral hypoxia
Brain damage/ death

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

10

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 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 patients lips and continuous
supervision
11

Additional methods in preservation of the airway in

patient with severe facial injuries

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
12

Cervical spine injury

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

13

Breathing and ventilation

Chest injuries:

Pneumothorax, haemopneumothorax, flail

segments, reputure daiphram, cardiac
tamponade

signs
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
14

Emergency treatment in case

of chest injury

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
15

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

16

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
17

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

18

Neurological deficient
Rapid assessment of neurological disability is made
by noting the patient response on four points scale:

Response appropriately, is Aware

Response to verbal stimuli

Response to painful stimuli

Does not responds, Unconscious

19

Glasgow coma scale (GCS)

(Teasdale and Jennett, 1974)

Eye
opening

Motor
response

Spontaneous 4 Move to
command
To speech
3 Localizes to
pain
To pain
2 Withdraw
from pain
none
1 flexes

Verbal
response
6 Converse

5 Confused

4 Gibberish

3 grunts

Extends

none

none

Score 8 or less indicates poor prognosis, moderate head injury

between 9-12 and mild refereed to 13-15

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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 for:

Accurate diagnosis
Maintenance of a stable state
Determination of priorities in treatment
Appropriate specialist referral

21

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
22

Head injury
Many of facial injury patients sustain head
injury in particular the mid face injuries

Open

Closed
it is ranged from Mild concussion to brain
death

23

Signs and symptoms of head injury

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 (battles sign)
Temporal/ frontal bone fracture
Naso-orbital ethmoidal fracture

24

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 patients
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
25

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)

26

Abdomen and pelvis

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

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Extremity trauma
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
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Patient hospitalization and

determination of priorities
Facial bone fracture is hardly ever an urgent
procedure,
simple and minor injury of ambulant patient may
occasionally mask a serious injury that eventually
ended the patients life

emergency cases require instant admission

conditions that may progress to emergency
cases with no urgency
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Preliminary treatment in complex

facial injury

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
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Prevention of infection
Fractures of jaw involving teeth bearing areas
are compound in nature and midface fracture
may go high, leading to CSF leaks
(rhinorrhoea, otorrhoea) and risk of meningitis,
and in case of perforation of cartilaginous
auditory canal

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
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(Eljamal, 1993)

Control of pain
Displaced fracture may cause severe pain but
strong analgesic ( Morphine and its derivatives)
must be avoided as they depress cough reflex,
constrict pupils as they may mask the signs of
increasing intracranial pressure
Management:
Non-steroidal anti-inflammatory drugs can
be prescribed (Diclofenac acid)
Reduction of fracture
sedation

32

In patient care

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