OS 500

SEMINAR
PRESENTATION
PRESENTER: ABEL K MHIKE
DDS5
2018-04-11920

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IMMEDIATE MANAGEMENT OF ORAL
AND MAXILLOFACIAL TRAUMA
• OUTLINE
• Introduction
• Primary survey
• Resuscitation
• Secondary survey

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INTRODUCTION
• Trauma is a global problem and continues to be a
leading cause of death and disability in both
developed and developing countries.
• It is the leading cause of death in persons aged 1
through 44 years in most developed countries.
• Trauma caused more than 300 million patients to
seek hospital care worldwide

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• It is projected to advance to the second leading
cause of death in all age groups worldwide by 2030.
• Motor vehicle accidents are projected to rise to the
fifth leading cause of death worldwide by 2030.

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• to evaluate a patient with multiple facial fractures
sustained during a roll-over motor vehicle accident.
• In these cases the patient may have other injuries
that require diagnosisand treatment.
• It is critical that the oral and maxillo-facial surgeon
has an understanding of the initial evaluation of the
trauma patient and can ensure that the appropriate
work-up was completed and more serious injuries
were either diagnosed or ruled out.

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Trimodal distribution of death
after trauma
• 1st Peak – At Scene (50%) takes place within seconds to minutes This
includes injuries to Brain Injury, Heart, or Major Internal Injury

• 2nd Peak – Within Minutes to Hours After (30%) Takes place minutes
to hours, includes Airway Obstruction, Chest Injury, Blood Loss (from
vascular injuries-exaquinations)

• 3rd Peak – Within Days to Weeks After (20%)

• Multiple Organ Failure, Sepsis, penetrating trauma to patient who
survived immediate injuries & need surgical haemostasis within the
wound tract, blunt trauma-need careful diagnosis & stabilization
before surgery.

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• Routine orderly evaluation of the trauma patient is
not indicated.
• Resuscitation takes priority over diagnosis to ensure
successful out come.
• To achieve this, a systematic approach using
advance trauma life support (ATLS) is
recommended.

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ADVANCED TRAUMA LIFE
SUPPORT (ATLS)
• ATLS involves tha identification and the correction
of most life threatening problems First in trauma
patient.
• It's consist of primary survey and secondary survey

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Triage
• Emergency medical teams are often the first to
evalu-ate injured patients.
• They are trained to rapidly triage the patients, so
priority is given to those patients and injuries which
are most serious or require urgent treatment, and
to determine if the patient’s injuries warrant
transport to a trauma center.

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PRIMARY SURVEY AND
RESUSCITATION
• Primary survey involves the ABCDE survey

• 1. Airway maintenance and C spine protection

• 2.Breathing and ventilation
• 3.Circulation
• 4.Disability
• 5.Exposure
• This is an initial resuscitation

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• In this survey you identify any immediate threat to
life and start treatment.
• The assessment should be very fast and should
follow the following sequence :
• -Airway and cervical spine control
• -Breathing & ventilation
• -Circulation & control of hemorrhage
• -Brain dysfunction
• -Exposure in a control environment
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Airway and cervical spine
protection
• The primary survey begins with an evaluation of the
patient’s airway while providing cervical spine
protection.
• Is the airway clear?
• Check mouth & pharynx for presence of foreign body
• Extend the neck in combined with forward
displacement of the jaw
• Insert an artificial airway (oropharyngeal or nasal
pharyngeal)
• Insert neck collar to protect the Cervical spine
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• Facial fractures and tracheal injuries should be
recognized as potential sources of airway
obstruction.
• Facial and neck soft tissue injuries and burns can
also progress to airway compromise.
• 15% of supraclavicule injuries Will have cervical
spine injury.
• Avoid excessive movement during airway
management.

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• Feel trachea deviation and tenderness and crepitus
• Perform chin lift and jaw thrust
• Chin lift perform without overextending the neck
And pull tongue forward.
• Jaw thrust Displacing the mandible forward on
either side at the angle of the mandible .

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• Patient without gag reflex , endotracheal on
nasotracheal intubation should be done
• Indications for intubation can be separated into
several broad categories:
• •inability to ventilate – airway obstruction, chest
trauma, paralysis and respiratory fatigue
• inability to oxygenate – inhalation injury, acute
respiratory distress syndrome (ARDS), pulmona ary
edema

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• airway protection – unconsciousness, altered
• mental status, facial or head trauma, oral bleeding,
aspiration risk (vomiting).
• If intubation it doesn't work once do not attempt
again And go for surgical airway opening
• Surgical airway opening is to do cricothyroidotomy.
• Needle cricothyroidotomy 12-14 gauge

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• Procedure for Surgical Cricothyroidotomy
• 1) Local Anesthetic
• 2) 3 cm horizontal incision through skin
• 3) 1 cm cut through cricothyroid membrane
• 4) Tracheal Dilator
• 5) Tracheostomy Tube
• 6) Inflate Cuff
• 7) Connect to O2 Supply
• 8) Auscultate Chest
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 Breathing and ventilation
• Looks for signs on inadequate or absent of
Breathing
• Central cyanosis ,check in the tongue
• No breathing heard or felt at the Mouth or nose
• Open patient chest for thorough inspection
• No activity of respiratory muscles

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Cont….
• Diminished or absent breath sounds may indicate a
pneumothorax or hemothorax (separation of the
visceral and parietal pleura with entry of air or
blood into the pleural space).
• There is an eventual shift in the mediastinum to the
contralateral side and com-pression of the major
vessels entering the chest.
• With compression there is a decrease in venous
return to the heart and resulting decline in cardiac
output

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Cont…
• This lesion is suspected in the patient with signs of
chest trauma, absence of breath sounds on one
side, hyper-resonance of the chest wall,
hypotension, and shift of the trachea to the
contralateral side

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• Immediate action to take
• Monitor patient oxygen on pulse oximetry
• Normal oxygen saturation level 98%-100%
• Ventilate the lung immediately by using Ventilation
with expired air Without intubation 16% of oxygen
• Ventilate with Self inflicted bellow (SIB) without
intubation
• Ventilate with SIB with intubation
• Correct identied causes
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• Conditions where the ventilation may be
compromised.
• 1.Direct trauma to the chest, like rib fractures,
leading to severe pain during breathing and leads
to shallow breathing and hypoxemia.
• 2. Elderly patients and other individual with
pulmonary dysfunction are at signifcant risk for
ventilator failure.

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• 3.Intracranial injury can cause abnormal breathing
patterns and compromised adequacy of ventilation.

• 4. Cervical spinal cord injury can result in

diaphragmatic breathing and interfere with the
ability to meet increased oxygen demands.

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• Life threatening conditions which compromise
breathing and ventilation.
• Airway Obstruction
• Tension Pneumothorax
• Open Pneumothorax
• Massive Hemothorax
• Flail Chest
• Cardiac Tamponade

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 Circulation and hemorrhage
control
• The initial assessment begins immediately.
• A quick evaluation of the patient’s level of
consciousness, skin color, and pulses can be
completed while monitors are being placedand
intravenous access established
• the patient with cold,clammy skin that appears
shine and grey may be severely hypovolemic.
• Early signs of a collapsing circulatory system are
tachycardia and peripheral vasoconstriction should
be notified .
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• Shock in the trauma patient is most likely caused by
acute blood loss.
• Immediate action to circulation is important with
securing with IV line
• Use two large Vein canulla or needle (gauge 14 or
16)
• If peripheral vein is invisible,use large veins like
Femoral vein ,external or internal jugular vein.

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• Control bleeding by firm pressure,for large vessels,
ligating blood vessel is indicated.
• Restore circulating volume
• Elevate the legs to increase venous return
• Resuscitation of shock begins with the administration of
2 l of crystalloid solution (normal saline, lactated
Ringer's solution).
• Further fluid resuscitation and the need to transfuse
blood are based upon estimates of the volume of blood
loss and the patient’s response to the initial fluid bolus.

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• Greater than 40% blood loss then blood transfusion
is indicated
• Urinary catheter and arterial lines are placed to
provide information on circulation
• Arterial catheter provide immediate monitoring of
patient blood pressure and provide access to
repeated laboratory samples
• Urinary catheter provide immediate monitoring of
urinary output.

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• Watch out for coagulopathies :the condition in
which blood ability to clot is impaired
• Blood transfusion
• 1.full cross match -one hour
• 2.Type specific -10 minutes
• 3.type O

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Disability
• The primary survey concludes with a rapid
neurologic evaluation.
• A decline in the patient’s level ofconsciousness may
be due to a decrease in cerebral perfusion or
cerebral oxygenation, or may be due to an
intracranial injury.
• A rapid neurologic assessment should include an
evaluation of sensory and motor function and
rectal tone

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• Other potential causes of an acute decline in level
of consciousness are hypoglycemia and alcohol or
drug intoxication.
• The Glasgow Coma Scale is a rapid objective clinical
measure of neurologic function.

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• Eye opening
• Spontaneous – 4
• To speech – 3
• To pain – 2
• None – 1

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• Motor response
• Obeys commands – 6
• Localizes to pain – 5
• Normal flexion (withdrawal) – 4
• Abnormal flexion (decorticate) – 3
• Abnormal extension (decerebrate) – 2
• Flaccid – 1

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• Verbal response
• Oriented – 5
• Confused conversation – 4
• Inappropriate words – 3
• Incomprehensible sounds – 2
• None-1

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• Score grades
• 14-15 mild
• 9-13-moderate
• 3-8 severe
• patient’s Glasgow Coma Score along with
mechanism of injury (blunt versus penetrating) and
type of head trauma (skull fracture, intracranial
lesion) are used to triage the patient’s neurologic
injuries.

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Exposure /environment control
• The primary survey concludes with complete
exposure of the patient.
• The patient should be undressed to allow for a
complete head to toe physical examination.
• It's critically to protect the patient from
hypothermia
• Hypothermia develops in up to 70% of trauma
patients at some point during resuscitation.

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• Exposure, paralysis, and fluid administration all
contribute to lowering the patient’s core
temperature.
• Hypothermia can produce a relative coagulopathy
It alters platelet function, the coagulation cascade,
and the fibrinolytic system.

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RESUSCITATION

• RE EVALUATE THE ABCD

• A. Airway
• Definite airway if there is any doubt about the patient’s
ability to maintain airway integrity
• B. Breathing
• Supplemental oxygen
• C. Circulation
• Control bleeding by direct pressure or operative
intervention
• Minimum of two large IV canula
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• Put the patient on monitors. Eg ECG, pulse
oximetry.
• Catheterize, insert NGT when necessary
• When necessary do necessary radiological
investigations
• CT scan of the head
• Chest X-rays
• C-spine X-ray

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SECONDARY SURVEY
• Complete history and head to toe physical
examination of the patient.
• This is initiated after primary survey is complished
and patient is stable
• A full maxillofacial facial examination is completed
• AMPLE history

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• History (AMPLE)
• A - Allergies
• M- Medicines
• P- Past illnesses
• L- Last meal
• E- Evaluation related to trauma

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• Maxillofacial
• 1.Examine scalp - Examine for lacerations,
contusions, fractures
• 2.Bony steps Orbits, frontozygomatic,
zygomaticomaxillary sutures, zygomatic arch,
mandibular pain, occlusal steps

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References
• Oral and maxillofacial surgery Edited by Las Anderson First
edition 2010.

• Peterson’s Principles of Oral and Maxillofacial Surgery -

Third Edition Editors Michael Miloro, DMD, MD, FACS G. E.
Ghali, DDS, MD, FACS Peter E. Larsen, DDS Peter D. Waite,
MPH, DDS, MD, FACS .
• Textbook of Oral and Maxillofacial Surgery Edited by Prof.
Dr. Neelima Anil Malik BDS, MDS (Bom) FIAOS Professor
and Head of the Department of Oral and Maxillofacial
Surgery – Associate Dean Nair Hospital Dental College,
Mumbai, Maharashtra, India.
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