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Management of maxillofacial trauma in emergency: An update of challenges and

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Article  in  Journal of Emergencies Trauma and Shock · April 2016

DOI: 10.4103/0974-2700.179456

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1
AQ1 Review Article 1
2 2
3 3
4 4
5
6 Management of maxillofacial trauma in emergency: 5
6
7
8 An update of challenges and controversies 7
8
9 9
10 10
11 Anson Jose, Shakil Ahmed Nagori, Bhaskar Agarwal, Ongkila Bhutia, 11
12 12
13
Ajoy Roychoudhury 13
14 Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, India 14
15 15
16 16
17 ABSTRACT 17
18 18
19 Trauma management has evolved significantly in the past few decades thereby reducing mortality in the golden hour. 19
20 However, challenges remain, and one such area is maxillofacial injuries in a polytrauma patient. Severe injuries to the 20
21 maxillofacial region can complicate the early management of a trauma patient owing to the regions proximity to the 21
AQ2
22 brain, cervical spine, and airway. The usual techniques of ABC management are often modified or supplemented with 22
23 other methods in case of maxillofacial injuries. Such modifications have their own challenges and pitfalls in an already 23
24 difficult situation. 24
25 25
Key Words: Airway management, bleeding, emergency care, facial injury
26 26
27 27
28 INTRODUCTION AIRWAY 28
29 29
30 Maxillofacial injuries are frequent cause of presentations in an The first and foremost maxillofacial injuries are usually 30
31 emergency department. Varying from simple, common nasal complicated by a compromised airway. On account of its 31
32 fractures to gross communition of the face, management location in the “crumple zone” of the face, even minor injuries 32
33 of such injuries can be extremely challenging. Injuries of can result in significant casualty to the airway. The situation may 33
34 this highly vascular zone are complicated by the presence be aggravated by diminished consciousness, alcohol, and/or 34
35 of upper airway and proximity with the cranial and cervical drug intoxication, as well as altered laryngeal and pharyngeal 35
36 structures that may be concomitantly involved. While, with reflexes, making the patient vulnerable to the risk of aspiration. 36
37 non maxillofacial injuries, a protocol for management of Furthermore, this scenario is complicated by the presence 37
38 airway, breathing, and circulation is relatively well established; of broken teeth, dentures, foreign bodies, avulsed tissues, 38
39 injuries to this region have often been a subject for discussion. multiple mandibular fractures, and massive edema of glottis 39
40 We present an overview of the initial management of such which can cause a direct threat to the airway. Alcohol, drugs, 40
41 patients in terms of airway, cervical spine, and circulation. and head injury along with ingested and pooled blood can 41
42 The challenges and controversies in the management of such trigger nausea and vomiting. The act of vomiting prompts a 42
43 patients are discussed. rise in intracranial tension which in turn increases the bleeding 43
44 44
45 Address for correspondence: 45
This is an open access article distributed under the terms of the Creative
46 Dr. Ajoy Roychoudhury, E-mail: ajoyroy@hotmail.com Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows 46
47 others to remix, tweak, and build upon the work non-commercially, as long as the 47
author is credited and the new creations are licensed under the identical terms.
48 Access this article online 48
49 Quick Response Code: 49
Website: For reprints contact: reprints@medknow.com
50 www.onlinejets.org 50
51 How to cite this article: We will update details while making issue 51
52 online*** 52
DOI:
53 ***
53
54 Received: 29.11.15. Accepted: 12.01.16. 54
55 55
56 56

© 2016 Journal of Emergencies, Trauma, and Shock | Published by Wolters Kluwer - Medknow 1
 Jose, et al.: Maxillofacial trauma: An update

1 and salivation that occludes the airway. Vomiting and risk of times with complete equipment to deal with, namely tracheal 1
2 aspiration are particularly high when patients are in supine tube introducer, supraglottic airway devices, combitubes, 2
3 position. Technically speaking, in patients with multiple facial endotracheal tubes, tracheostomy set, and craniotomy kit.[4] When 3
4 fractures, the displacement of maxilla or mandible posteriorly management by conventional definitive airway is less likely, it is 4
5 can decrease the airway patency[1] [Figures 1 and 2]. Although prudent to have an experienced team at hand for establishing 5
6 of less frequency, injuries to larynx and trachea can also create rescue surgical airway. 6
7 airway embarrassment. 7
8 Strictly speaking, irrespective of the injury, maxillofacial 8
9 trauma patients should be given adequate oxygenation with 9
MANAGEMENT
10 uninterrupted saturation monitoring. The spinal collars should be 10
11 applied with extreme caution to prevent any inadvertent posterior 11
Despite recent major medical advancements, the basic
12 displacement of mandible thus complicating airway. Contrary to 12
fundamental of airway management remain the same. Upper
13 other polytrauma, the airway of maxillofacial patient is at constant 13
airway obstruction due to craniomaxillofacial trauma invariably
14 risk. Hence, the strategy is a systematic analysis of the airway as 14
results in a threatened airway. The potential concomitant injury
15 delayed airway compromise may occur due to the displacement 15
to other organs and the presence of an unclear C-spine further
16 of tissue, bleeding, and swelling.[2] High-volume suction should 16
complicates airway management. A variety of airway handling
17 be available to clear the mouth and oropharynx from blood 17
techniques are currently available. However, nothing is a fool
18 and secretions.[5] However, care should be taken not to irritate 18
proof and should be tailored according to a particular situation
19 the oropharynx with suctioning as it predisposes the patient to 19
depends on the magnitude and type of the injury. Supervision
20 vomiting. In addition, careful monitoring of patient at this instant 20
of an emergency situation like this demands the experience and
21 shall provide an idea about the response of protective reflexes 21
technical skills of the emergency operator and he or she should
22 such as gagging and swallowing. Oropharyngeal guedel can be 22
always prognosticate airway obstruction and be qualified enough
23 used effectively, once airway is clear. However, the placement of 23
to perform a surgical airway.
24 guedel itself induces retching, laryngospasm, and often displaces 24
25 the tongue posteriorly thereby further aggravating airway. In 25
Initial assessment
26 the absence of any protective reflex, emergency endotracheal 26
The strategy of look, listen, and feel helps to figure out airway
27 intubation is the rule. In patients with a patent airway and absent 27
obstruction and anticipated airway complications.[2] The airway
28 spontaneous breathing, bag-mask ventilation is the procedure 28
management approach, particularly in unconscious trauma
29 of choice. A tightly fitted mask with concurrent jaw thrust 29
patients should be complimented with the protection of C-spine.
30 is often enough to maintain ventilation. Nonetheless, obese 30
In high-velocity trauma which involves the mandible, swallowing
31 patients and patients with beard possess problems thus reducing 31
mechanism is altered due to pain and ineffective protective reflex
32 the effectiveness of ventilation. Preferably, mask ventilation in 32
modulation, results in difficulty to keep the airway clear.[3] Hence,
33 trauma patients should be a “two-person technique,” one holding 33
it is important to protect the airway from blood and vomitus to
34 the mask tightly fitted to mouth and the other operating the bag. 34
prevent aspiration and further pulmonary complications. The
35 Similarly, adjunctive airway maneuvers such as chin lift and jaw 35
palpation of trachea reveals any collapse or deviation. Larynx
36 thrust should be performed with care. Head tilt and “sniffing 36
should be auscultated for stridor. The presence of any tracheal
37 the morning air” positions are absolute contraindications in case 37
tug or laryngeal stridor explains an impending threat to the
38 of suspected C-spine injury. In patients with suspected C-spine 38
airway. The “difficult intubation” tray should be accessible all
39 39
40 40
41 41
42 42
43 43
44 44
45 45
46 46
47 47
48 48
49 49
50 50
51 51
52 52
53 53
54 54
55 55
Figure 1: Posteriorly displaced bilateral parasymphyseal Figure 2: Airway in severely communited midface fracture can be
56 mandibular fracture can complicate the airway challenging to manage 56

2 Journal of Emergencies, Trauma, and Shock I 9:2 I Apr - Jun 2016

 Jose, et al.: Maxillofacial trauma: An update

1 injury, the management protocol is to keep the patient supine anatomy as in complex maxillofacial trauma may cause injury to 1
2 to further reduce C-spine morbidity as well as immobilizing the the trachea, larynx, and esophagus when not properly placed.[11] 2
3 cervical spine using hard cervical collars. Such collars may reduce Although suggested, retrograde intubation through cricothyroid 3
4 visibility to the oropharynx that may be of considerable important. puncture is very time-consuming and required expertise. Hence, 4
5 Unfortunately in this scheme, the question to be answered is it is of limited use in emergency.[12] During airway maintenance 5
6 how effectively a trauma team can intubate the patient? On this technique, the manipulation of cervical spine should be kept 6
7 account, a study reveals that trauma patients present with noisy or minimal and whatever method you follow, always remember the 7
8 clogged airways. The unsuccessful intubation rate is an alarming dictum “to do no further harm.” 8
9 12%.[6] While in a study by Martin et al.,[7] out of 3423 emergent 9
10 intubations performed, 10.3% required multiple attempts and When noninvasive techniques for securing airway fail, the surgical 10
11 were classified as “difficult.” airway is the only available option. They are of two types: 11
12 Cricothyroidotomy and tracheostomy.[13] The cricothyrotomy 12
13 Definitive airway is the most convenient method in emergency and can be 13
14 The concept of the definitive airway is maxillofacial trauma performed by needle (needle cricothyrotomy) or by surgical 14
15 is probably much more important as compared to trauma to scalpel (surgical cricothyrotomy).[14] Although some schools 15
16 other body parts. The primary indications are given in Table 1. advocates needle cricothyrotomy, its standard use is debatable. 16
17 Conventional straightforward definitive airway options are The failure rates and insufficient oxygenation precludes it use, 17
18 orotracheal intubation, nasotracheal intubation, and surgical and surgical cricothyroidotomy is the pertinent method of 18
19 airway. Orotracheal intubation with the aid of laryngoscope choice in emergency. Tracheostomy in most of the cases is 19
20 is the most feasible and safest method of choice. However, if performed as an elective procedure, once the patient is stabilized 20
21 the C-spine is not clear, it is prudent to perform manual axial by cricothyrotomy. Despite percutaneous tracheostomy claims 21
22 in-line stabilization during orotracheal intubation. Although to reduce the operative time and surgical risks in good hands, its 22
23 evidence in literature imparts that some cervical movement is routine use is not indicated in emergency. 23
24 inevitable,[8,9] orotracheal intubation is comparatively safe in an 24
25 unclear cervical spine. It is easier to perform, quick and causes Protocol for airway management in maxillofacial 25
26 minimal mobilization of the cervical spine in skilled hands.[10] In trauma [2] 26
AQ3
27 severe avulsive facial injury or in laryngeal or tracheal collapse, • Anticipate and recognize an airway obstruction 27
28 placement of orotracheal tube is challenging, and surgical • Clear the airway, position the patient. Perform chin lift and 28
29 airway is the choice. Nasotracheal intubation is another effective jaw thrust maneuver 29
30 alternative and can be achieved in patients without communited • Confirm the nasal and oral aperture are clear then use 30
31 midface or skull base injury. This is of particular importance artificial airways and 31
32 in managing airway obstruction due to lower face injury and • Perform bag-valve-mask ventilation. Preferably “two-person 32
33 suitable for patients in which the mouth opening is inadequate. technique” 33
34 The methods are of two types either blind or fiberoptic assisted. • Oroendotracheal intubation 34
35 The traditional blind technique by a trained professional is quick, • In unsuccessful orotracheal intubation or “cannot ventilate 35
36 effective and does not need premedication. The enthusiasm cannot intubate situation” perform surgical airway [Figure 1]. 36
37 toward fiberoptic technique, on the other hand, is limited by the 37
38 presence of copious secretions or blood in the airway, technique Controversies and pitfalls 38
39 sensitivity, and increased time required. Similarly, laryngeal In the management of airway, the most important perspective 39
40 mask airway (LMA) and combitube, although not a definitive is to facilitate a patent airway and protect the airway from 40
41 one, are alternatives to a failed or difficult intubation. These saliva, blood, and full stomach. It varies from the simple tactic 41
42 devices purchase time by bridging the airway until a definitive of patient positioning to complex surgical procedures depend 42
43 airway is achieved. However, it does not protect the airway from on the degree of injury and propensity of anticipated airway 43
44 regurgitation and aspiration. Little expertise required and easy obstruction. The effectiveness of the jaw thrust maneuver in 44
45 placement allow the combitube to be used blindly in emergency multiple fractures, especially in communited mandible fracture is 45
46 or in prehospital settings. However, its use in patients with altered debatable. Apart from having only a finite potential to enhance 46
47 the airway, the traction movements employed in this method 47
48 further increases the likelihood of bleeding and associated 48
Table 1: Indications for definitive airway
49 damage. Likewise, bag-mask ventilation is potentially hazardous, 49
Indications of definitive airway in maxillofacial injury
50 especially in Le Fort II, III, and nasoethmoidal fracture with 50
Absent spontaneous breathing
51 Comatose patient (glasgow coma scale <9) suspected fracture of the anterior cranial fossa. Mechanical 51
52 Airway injury or obstruction ventilation to maintain the oxygen saturation carries the risk 52
53 Persistent oxygen saturation <90% of forcing infectious material into a basilar skull fracture and 53
54 High-risk for aspiration displacing nasal debris and foreign particles into the brain. The 54
55 Systemic shock (systolic blood pressure <80) fear of tension pneumocephalus particularly when there is a tear 55
56 “Cannot ventilate cannot intubate” situations
in dura, by this route of ventilation, is not well known among 56

Journal of Emergencies, Trauma, and Shock I 9:2 I Apr - Jun 2016 3

 Jose, et al.: Maxillofacial trauma: An update

1 Initial 1
2 assessment 2
3 3
4 4
5 Suspected C-spine injury
5
6 6
7 Oxygenate/Ventilate-Bag Mask, 7
Oropharyngeal airway.
8 8
Spontaneous breathing +ve
9 Spontaneous breathing -ve 9
10 10
11 Attempt Orotracheal intubation 11
12 Anticipate Airway Obstruction Normal 12
13 13
14 If unable to intubate 14
Reassess and
15 Nasotracheal/orotracheal
Proceed
15
16 Rescue airway devices e.g., 16
17 LMA, Combitube 17
18 Pharmocologic Adjuncts 18
19 19
20 Retry orotracheal intubation
Orotracheal
20
21 21
22 If unable to intubate 22
23 23
24 Surgical Airway 24
25 25
26 26
27 Confirm Correct Tube Placement
27
28 (EtCO2 ,SpO2) 28
29 29
AQ7
30 Figure 3: Management of airway in maxillofacial trauma 30
31 31
32 emergency clinicians.[15-18] This is a life-threatening condition and Cricothyrotomy on the other hand, having an airway apparatus 32
33 can cause rapid deterioration of Glasgow Coma score (GCS) and that is adjacent to a surgical field could possibly cause wound 33
34 late neurological problems.[18] Although endotracheal intubation contamination and cut down access while definitive repair of 34
35 is the gold standard definitive airway, one of its potential maxillofacial trauma is carried out by an extra oral route. 35
36 drawbacks is difficulty in assessment of GCS. Extensive edema 36
37 of the glottis and retropharyngeal hematoma from fractured A meta-analysis by Hubble et al.[24] has shown that the success rate 37
38 spine complicated the use of orotracheal intubation. The of needle cricothyrotomy is 65.8% and surgical cricothyrotomy 38
39 nasotracheal intubation is generally contraindicated in patients is 90.5% when performed in emergency. Despite the popularity 39
40 with communited midface fracture due to the fear of iatrogenic of percutaneous tracheostomy in the last few years, there is no 40
41 penetration of tube via fracture of associated skull base.[11] In scientific evidence that the closed technique is superior or easier 41
42 a study by Rosen et al.[19] on 82 patients with midface fractures, than the standard tracheostomy in emergency.[25,26] A semi-open 42
43 no incidence of such tube penetration was noted. The authors tracheostomy is an innovational alternative in patients with 43
44 noted that this potential complication is a matter of concern C-spine injury and nonpalpable trachea. This is achieved by 44
45 only in central anterior skull base fractures. Similarly, only three performing a 2–3 cm skin incision to expose the pretracheal 45
46 cases of iatrogenic intracranial displacement have been reported fascia and subsequently by a percutaneous method. 46
47 in literature.[20-22] Thus, nasotracheal intubation in not an absolute 47
48 contraindication in maxillofacial trauma; in fact, it may be 48
CERVICAL SPINE AND MAXILLOFACIAL TRAUMA
49 the preferred mode of intubation in conscious patients since 49
50 this need not require neck manipulation or premedication for 50
In a complex maxillofacial trauma scenario, cervical spine
51 sedation and muscle relaxation. Failure to perform endotracheal 51
fracture should always be considered unless proven otherwise.
52 intubation necessitates the use of supraglottic devices (LMA) 52
The incidence is very less and ranges from 1% to 10% in all
53 until a definitive airway is maintained. These devices do not seem 53
maxillofacial trauma.[27-32] Because of the proximity of cervical
54 to prevent aspiration and are likely to exaggerate gagging, airway 54
spine any force of such magnitude that causes facial fractures
55 resistance, and oropharyngeal decubitus effect.[23] A patient with 55
can potentially traumatize the c-spine and its ligamentous
56 56
laryngeal injury is also an absolute contraindication for LMA. attachments.
4 Journal of Emergencies, Trauma, and Shock I 9:2 I Apr - Jun 2016
 Jose, et al.: Maxillofacial trauma: An update

1 The clearance of cervical spine consequent to an injury is an area and one not in 454 patients. It can conclude that in trauma 1
2 of much debate and discussion.[33-36] Clinical awareness about the the initial impact may cause spinal injury, however, careful 2
3 status of cervical spine is achieved using the most commonly movement or handling the neck is unlikely to cause further 3
4 used three evidence-based decision protocols, namely Nexus harm. In addition, even in case of undiagnosed injury, that 4
5 criteria,[37] Canadian spine rule,[38] and Harborview criteria.[39] In muscle splinting and pain is the best restraint and is excellent 5
6 patients who are awake, clearance protocol can be effectively or superior to any externally applied devices. Conscious patients 6
7 implemented by a detailed clinical examination; however, in an find an appropriate stable position which is most befitting for 7
8 unconscious patient, it is not possible. The clearance of such their particular type of injury.[46] Application of cervical collar 8
9 patients hinges on clinical examination, risk, and radiographic is logical in patients those who are incapable of protecting their 9
10 examination such as noncontrast computerized tomography,[40] spine as in an unconscious patient or patient under the leverage 10
11 static flexon extension radiography,[41] magnetic resonance of drugs. It is also sensible when the general status of the patient 11
12 imaging,[42] and dynamic fluoroscopy.[43] Generally, without the is declining, or the management of patient requires sedation and 12
13 adjunct of radiographic survey, the patient can be excluded from anesthesia.Nevertheless, a perfectly applied collar by trained 13
14 spine injury if they display the following:[37] personnel allows a minimum 30° of flexion/extension/rotation 14
15 • Patient with perfect neurological condition. (normal GCS) movement of the neck.[34] Ben-Galim et al.[47] has shown there 15
16 • Not under the consequence of drugs (alcohol, others) is an average 7.3 mm of hyperextension between C1 and C2 16
17 • Absence of pain/tenderness in posterior midline of cervical while wearing a collar. Another cadaveric study quoted that 17
18 spine significant amount of movement occurs to C-spine while placing 18
19 • Devoid of distracting, painful impairments. and removing of collars.[48] If it is so, studies have proved that 19
20 a sandbag will offer better protection and immobilization 20
21 However, there is a continuing debate about the credibility of than a rigid collar.[35] Furthermore, the cervical collar has 21
22 these clinical protocols in C-spine without the aid of radiographic been associated with a number of disadvantages that include 22
23 assessment. In a neurologically unstable patient, the cervical spine reduced access for orotracheal intubation, central venous access, 23
24 must be immobilized irrespective of the injury. The universally increased intracranial pressure, and problems with surgical 24
25 accepted method of C-spine management includes hard collars, management of maxillofacial trauma.[49,50] Thus, collar we 25
26 block and straps, and manual axial inline stabilization. These use in the emergency department or prehospital setting may 26
27 management methods are rather emotional and lack adequate neither provide any benefit nor protection against secondary 27
28 scientific basis, especially in conscious patients.[36] However, the injuries. There is no scientific evidence for that. Nonetheless, 28
29 generally accepted fact is that the application of collar protects the practice of using a cervical collar is recommended by us 29
30 and stabilizes the cervical spine temporarily until definitive taking into account of the fact that all emergency departments 30
31 management is done. The cervical collar should be applied by and prehospital conditions may not be optimally equipped ideal 31
32 an experienced person or a person trained to do that. It should for a careful and convenient transit. 32
33 be snugly fitted to aid immobilization and while applying care 33
34 should be taken not to compress the neck. Improper applications 34
35 of collars are implicated in airway obstruction and perhaps rise CIRCULATION AND HEMORRAGHE CONTROL 35
36 in intracranial pressure by affecting the venous return from 36
37 the brain.[44,45] This complicates head injury and increases the After the acquisition of airway and addressing breathing problems, 37
38 cerebrospinal fluid leakage form skull base fractures and creates attention must be given to circulation. Maxillofacial injuries 38
39 problems during operative repair of maxillofacial injuries. are very prone to massive hemorrhages, and life-threatening 39
40 hemorrhage can vary from 1.4% to 11%.[51-55] One out of every 40
41 The misconception trailing spinal immobilization following ten complicated facial fractures bleeds significantly. The main 41
42 trauma described by Benger et al.[46] is as follows: vessels involved are an ethmoid artery, ophthalmic, vidian branch 42
43 • Injury to cervical spine is a potential complication in trauma of internal carotid, and maxillary artery.[54,56,57] In most cases, 43
44 patients bleeding can be are easily controlled, but rarely severe epistasis 44
45 • Additional movement of cervical spine after trauma causes that ranges from 2% to 4%[55] of all facial trauma arises from 45
46 supplementary damage to C-spine the maxillary artery, creating difficulty in hemorrhage control. 46
47 • The wearing of cervical collars helps in immobilization and It is important to differentiate bleeding from the skull base 47
48 stabilizes C-spine fracture and oral bleeds by careful observation of pharynx for 48
49 • As a safety measure, it can be applied to all patients since it lacerations and tears. Patients with multiple maxillofacial injuries 49
50 is “harmless.” must be taken care. Otherwise, they will go into hemorrhagic 50
51 shock even though only 1.4%[51] such cases have been reported. 51
52 Trauma patient may have an unstable spine injury. However, the In the supine position, bleeding into oropharynx and swallowed 52
53 incidence is low (1.7%), of which only 0.1% shows significant blood in a conscious patient may cause vomiting thus, risking 53
54 neurological problems.[38] Hauswald et al.[33] found no convincing the C-spine.[58] Hence, the purpose of hemostasis in maxillofacial 54
55 differences in neurological events in a study comparing two trauma patient, is two-fold, namely to protect the airway, and to 55
56 countries, in which one follows strict spinal immobilization reduce blood loss. 56

Journal of Emergencies, Trauma, and Shock I 9:2 I Apr - Jun 2016 5

 Jose, et al.: Maxillofacial trauma: An update

1 Control of hemorrhage can be achieved by pressure packing, early correction. Two large bore IV lines should be placed for 1
2 manual reduction of fractures,[54] balloon tamponade,[59] and replacing fluid loss; similarly, exclude other concealed bleeding 2
3 in severe cases with angiography followed by trans-arterial from the thorax, abdomen, and vascular injury of other vital 3
4 embolization[60-63] or in some cases with direct external carotid organs.[68] Coagulopathy if any should be corrected. Temporary 4
5 artery (ECA) ligation[64] [Figure 4]. Severe nasal bleeding may stabilization of patient allows for any further resuscitation, 5
6 continue even after adequate anterior and posterior nasal clinical and radiographic investigations, and definitive care. 6
7 packing [Figure 5]. Sakamoto et al.[60] found that Foley’s catheter 7
8 balloon tamponade and ECA ligation does not respond in 8
9 72.2% of epistaxis. Balloon tamponade should be used with CONCLUSION 9
10 caution in communited midface fracture since it may cause 10
11 displacement of fractured fragment into orbits and brain.[59,65] The gravity of all maxillofacial injuries lies in the fact that they 11
12 The effectiveness of surgical exploration and ECA ligation pose an immediate threat to life as a consequence of its proximity 12
13 particularly in cases of nasoorbital ethmoidal fracture are proven to both the airway and brain. All the same, each case is unique; 13
14 ineffective due to superfluent collaterals from the internal carotid thus, the management is exacting even for the most experienced 14
15 artery at this region.[66] In uncontrolled bleeding that does not of professionals. In any given scenario no treatment approach can 15
16 respond to noninvasive methods, angiography and selective be described as being sure and flawless. The need of the hour is 16
17 embolization of bleeder is the method of choice. Nevertheless, a multipronged approach requiring a partnership between several 17
18 the use of trans-arterial embolization in managing epistaxis is departments. While new technology and material developments 18
19 not favored by many authors except in firearm injuries on the have helped ease the situation, it is the timely intervention, 19
20 area of anastomoses of external and internal carotid system.[54] sheer skill, and presence of mind of emergency personnel, and 20
21 However, these anastomoses have an increased risk of passage surgeons that counts. 21
22 of embolic material into the brain causing serious neurological 22
23 problems. The complications of selective embolization have Financial support and sponsorship 23
24 been reported in 50% population, which includes seventh Nil. 24
25 nerve palsy, trismus, necrosis of tongue, blindness, migration 25
26 of emboli into internal carotid, and eventually a stroke.[67] Once Conflicts of interest 26
27 bleeding is controlled maxillofacial injuries not always require There are no conflicts of interest. 27
28 28
29 29
Clear airway/
30 suctioning 30
31 31
32 32
33 Identify source of bleeding 33
34 34
35 35
36 36
37 37
Nasal Intraoral
38 Extraoral-Face/Scalp 38
39 39
40 40
Suture/Pressure
41 41
Anterior Posterior Bone Soft Tissue
42 42
43 43
44 Reduction
44
Balloon Tamponade Pressure packing Balloon Tamponade Stay sutures
45 of fracture 45
46 46
47 47
48 48
49 If Persistent Bleeding 49
50 50
51 51
52 52
53 Trans Arterial Embolization 53
OR ECA ligation
54 54
55 55
56 Figure 4: Management of bleeding in maxillofacial trauma 56

6 Journal of Emergencies, Trauma, and Shock I 9:2 I Apr - Jun 2016

 Jose, et al.: Maxillofacial trauma: An update

1 15. Dacosta A, Billard JL, Gery P, Vermesch R, Bertrand M, Bertrand JC. 1

2 Posttraumatic intracerebral pneumatocele after ventilation with a mask: 2
Case report. J Trauma 1994;36:255-7.
3 3
4 16. Nicholson B, Dhindsa H. Traumatic tension pneumocephalus after blunt 4
head trauma and positive pressure ventilation. Prehosp Emerg Care
5 5
2010;14:499-504.
6 6
17. Gurajala I, Azharuddin M, Gopinath R. General anaesthesia with laryngeal
7 7
mask airway may cause recurrence of pneumocephalus in a patient with
8 head injury. Br J Anaesth 2013;111:675-6. 8
9 18. Moon HS, Lee SK, Chung SH, Chung JH, Chang IB. Recurred
9
10 pneumocephalus in a head trauma patient following positive pressure 10
11 mask ventilation during induction of anesthesia -A case report. Korean J 11
12 Anesthesiol 2010;59 Suppl:S183-6. AQ512
13 19. Rosen CL, Wolfe RE, Chew SE, Branney SW, Roe EJ. Blind nasotracheal 13
14 intubation in the presence of facial trauma. J Emerg Med 1997;15:141-5. 14
15 20. Horellou MF, Mathe D, Feiss P. A hazard of naso-tracheal intubation. 15
16 Figure 5: Anterior and posterior nasal packing is usually the first Anaesthesia 1978;33:73-4. 16
17 choice for severe maxillofacial bleeding 21. Marlow TJ, Goltra DD Jr., Schabel SI. Intracranial placement of a 17
18 nasotracheal tube after facial fracture: A rare complication. J Emerg Med 18
19 REFERENCES 1997;15:187-91. 19
20 22. Goodisson DW, Shaw GM, Snape L. Intracranial intubation in patients 20
21 1. Hutchison I, Lawlor M, Skinner D. ABC of major trauma. Major with maxillofacial injuries associated with base of skull fractures? J Trauma 21
maxillofacial injuries. BMJ 1990;301:595-9. 2001;50:363-6.
22 22
23 2. Fonseca R, Barber H, Powers M, Frost D. Oral and Maxillofacial Trauma. 23. Bonanno FG. Issues of critical airway management (Which anesthesia; 23
4th ed. St. Louis: Saunders; 2012. which surgical airway?). J Emerg Trauma Shock 2012;5:279-84.
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