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Canad. Med. Ass. J. Jan. 28, 1967, vol.

96

Emergency Health Services 219

Emergency Care of Maxillo-Facial Injuries


DOUGLAS TANNER,

M.B.E., D.D.S., B.Sc.D,* Ottawa, Ont.


Les blessures interessant la face et les maxillaires doivent recevoir des soins immediats, comportant r&ablissement d'une aeration convenable, Farret de I'hemorragie et le traitment du choc. Parmi les mesures vitales indispensables, notons le soutien des structures de la face et l'obligation de placer le patient, face vers le bas. L'inqui&ude manifested par le malade concernant l'apparence de la face exerce une influence dfavorable sur sa guerison. II est de premiere importance d'eVacuer rapidement le malade vers un Centre de traitement avance, pour lui prodiguer des soins medicaux et

importance.

Support of the facial structures and positioning of the patient face-downwards are essential lifesaving measures. Anxiety concerning facial appear ance has an adverse influence on the patient's re covery. Early evacuation to an Advanced Treatment Centre for medical and dental care is of prime
treatment must

treatment such as the establishment of a free airway, control of hemorrhage and treatment of shock.

Maxillo-facial injuries require immediate first-aid

is necessary.

of maxillo-facial be taken if life is to be saved and dental functions and facial appearance restored. These requirements can only be provided by a highly skilled integrated medical and dental team. Following a disaster, first-aid treatment must be rendered as quickly as possible, and of necessity this will probably be undertaken by para-professional persons. The following are general types of maxillofacial injuries which will have to be cared for by first-aid workers at the first echelon and con tinued under professional supervision at the second echelon.1 1. Civilian type: Injuries in this class are due to minor accidents, fails, fist blows, and so forth. They are characterized by simple linear fractures which are frequently compound but rarely comminuted. There is little bone displacement or loss of tissue. There is no shock and the general condition of the patient is good. 2. Crush type: The crushing action of failing masonry, and motor-car and aeroplane accidents produce multiple comminuted fractures with great displacement of tissues. Bruising of the tissues and shock are usually severe. 3. Gunshot- (GSW) and shell-wound type: Missiles travelling at a high velocity produce grossly comminuted compound fractures with loss of bone and soft tissue. When a bullet shell fragment, or other hard substance, enters the face, the entrance wound, according to the size of the fragment, is relatively small. The penetra tion fractures and comminutes the bone, carrying fragments into the soft tissues, resulting in gross destruction. The exit wound is large and there is a great loss of tissue. Clothing, dirt, and so forth, are carried into the wound by the foreign body, causing sepsis, and debridement

the INinjuries,emergency special

dent aires.

care

Injuries in this classification combination of the "crush" and "GSW" types. The tissues are subjected to crushing as well as compound injuries from flying objects. Severe shock is common in this type of injury. Initial first-aid treatment includes life-saving measures such as the establishment of a free air way, control of hemorrhage and treatment of shock. Concurrent injuries should be noted and evaluated. A barrel bandage support should be applied to the mandible in order to maintain the free airway and prevent further hemorrhage fractured by movement of the shock as aparts. There is a result. marked reduction in If the victim is conscious, one can readily assess the status of respiration, the degree of shock and concurrent injuries. If the patient is unconscious, the assessment of these factors will tax the observer's diagnostic abilities to the
4. Air-raid type:
are a

utmost.

?Director of Dental Services, Department of Veterans Affairs, Ottawa 4, Ontari.

The first consideration is the establishment of unobstructed airway. When the mandibular genial symphysis is destroyed, the fails attachment backward, obof the tongue is lost and it the glottis. Respiration is difficult be structing cause of edema of the soft tissues of the floor of the mouth and the accumulation of blood, saliva and foreign bodies, such as dentures, bone fragments and teeth, in the throat. The patient should be placed in a face-downward position, the tongue pulled forward and the airway cleared, using one's fingers as a rake. If the genial attachment is lost, it will be neces sary to pass a suture through the tongue or even a safety pin with string and attach it to the skin of the face with an adhesive bandage. Thus the tongue will be maintained in an extruded position and the airway unobstructed. Trache otomy is seldom necessary but should be per formed without delay when the occasion demands.
an

220 EMERGENCY HEALTH SERVICES

Canad. Med. Ass. J. Jan. 28, 1967, vol. 96

The control of hemorrhage is rarely a difficult procedure. Pressure bandages will usually suffice. When respiration is restored and hemorrhage controlled, a barrel bandage should be applied to the jaws to immobilize the facial structures. This will be a continuing aid to the maintenance of the airway, control of hemorrhage, relief of pain and reduction of shock. When this support is being applied, care must be taken to conserve all attached bone and soft tissue fragments. Loss of such fragments complicates future surgical repair and results in dental malfunction and distortion of facial features. Every effort should be made to prevent or reduce shock. Such efforts can be instituted by the first-aid worker at the first echelon of treatment (Casualty Collecting Units), and patients should be awarded high priority of evacuation to the second echelon (Advanced Treatment Centres) for continuation of treatment by professional staff. The patient's anxiety over his facial disfigurement is strong and may contribute to the development of shock. Kindness and reassurance

are, therefore, essential in all stages of treatment. The patient should always be face-downward, whether lying, sitting or standing. This permits the discharge from the mouth of saliva, blood and foreign bodies. If these first-aid measures are administered in the field, the patient should arrive at a maxillo-facial centre in a condition conducive to the best surgical restoration of function and facial appearance.
SUMMARY Maxillo-facial injuries require immediate first-aid for the establishment of a free airway, control of hemorrhage, and treatment of shock. The facial structures must always be supported and the patient kept in a face-downward position. Anxiety of the patient for his facial appearance is a distressing factor which must be considered in all stages of treatment. Early evacuation to an Advance Treatment Centre for professional care is of prime importance.
REFERENCE 1. TANNER, D.: J. Canad. Dent. Ass., 12: 163, 1946.