Lec.1 General Management of The Patient With Facial Injuries
Lec.1 General Management of The Patient With Facial Injuries
Lec.1 General Management of The Patient With Facial Injuries
• First peak
• Second peak
Occurs between a few minutes after injury and about one hour later
(golden hour). Death is attributed to unrecognized serious complications,
such as airway compromise, hemorrhage, and head injury.
• Third peak
Occurs some days or weeks after injury when sepsis or multi-organ failure
occur and lead to death.
The advanced trauma life support (ATLS) was developed
by the American College of Surgeons Committee of Trauma
to ensure a quick and efficient evaluation of the patient’s
injuries and almost-simultaneous lifesaving intervention.
Obstruction of airway
asphyxia
Cerebral hypoxia
✓ Tachycardia
✓ Hypotension
✓ Narrowing pulse pressure (systolic minus diastolic)
✓ Tachypnea
✓ Delayed capillary return
✓ Falling urinary output
✓ Deteriorating mental status (i.e., increasing confusion)
The source of bleeding can be external or internal, must
be controlled by :
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It is always important to reserve blood for cross-
matching, blood transfusion may be required
to compensate blood loss and avoid
hypovolemic shock.
Shock:
Acute circulatory collapse is not usually a
prominent feature of a fracture of the facial
skeleton, and if such a patient is severely
shocked the possibility of the coexistence of
some other more serious injury should be
suspected.
Disability due to neurological deficit
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This, coupled with an assessment of the pupil reaction,
allows rapid assessment of the degree of head injury.
Documenting the pupillary response and repeatedly
examining the pupillary response to light directly and
consensually until the patient is stable are important.
Ipsilateral dilating pupil after maxillofacial trauma may
be due to:
✓ Direct injury to the eye
✓ Optic nerve damage
✓ Oculomotor nerve compression
✓ It may be a sign of an increase in intracranial
pressure especially when combined with decreased
level of consciousness.
Glasgow coma scale
It is a method of neurological assessment of the level
of consciousness; it provides a reliable, objective way
of recording the conscious state of a patient. It can be
used for initial evaluation as well as regularly
recording improving or deteriorating status. It should
be noted, however, that hypoglycaemia, alcohol and
drug abuse may also alter the level of consciousness
and should also be excluded. Points are awarded
using the criteria given in the scale to give a total
score between 3 (deeply unconscious and
unresponsive) and 15 (fully conscious, alert and
orientated).
Any patient with a GCS score of less than 8 should be
considered as unable to protect their airway.
Glasgow coma scale (GCS)
(Teasdale and Jennett, 1974)
Accurate diagnosis
Maintenance of a stable state
Determination of priorities in treatment
Appropriate specialist referral
Head Injury
The cranium should-be-palpated- and
inspected for evidence of lacerations and
bony damage and the level of consciousness
determined.
Eyes
The eyes should be examined at an early stage both as part of
neurological examination and to determine whether there has been
any physical injury to the globe. Vision, pupil size and reaction to
light should be recorded.
The spine
The whole spine should be carefully palpated, particularly in the
vulnerable cervical area. Immediate radiographic examination should
be carried out prior to movement if a fracture is suspected.
The limbs
Rapid palpation of the limbs for deformity or bony tenderness should
precede the recording of reflexes.
Abdomen and chest
Examination by inspection and palpation will determine whether there
is a possibility of visceral injury or fracture of the chest wall or pelvis.
The first urine specimen should be examined for the presence of
blood. The operator will by this time have enough information to call
for any assistance he may require from other specialties.
Orbital Compartment Syndrome
( Retrobulbar oedema ):
follow orbital or facial trauma resulting in diffuse
tissue swelling, retrobulbar pressures cause
optic nerve ischemia ,
Signs and symptoms of retrobulbar hemorrhage:
1.Pain increasing)
2.Decreasing visual acuity
3.Diplopia
4.Proptosis
5.Tense globe
6.Subconjunctival oedema chemosis
7.Dilated pupil
8.Loss of direct light reflex
9.Ophthalmoplegia (paralysis of ocular
it should be managed medicaly with:
-Mannitol 1 gm /kg
-acetazoiamide 250-500 mg to reduce intra
ocular pressure
-3 4 mg/kg iv dexamethasone to reduce oedema
Retrobulbar hemorrhage:
require evacuation through lateral canthotomy as
emergency before surgery), so buy time’ by doing
both as an emergency while preparing for
surgery. Irreversible ischemia of the visual
pathway can occur within 1 hour, an permanent
visual loss (blindness) within 1 hours .
Soft Tissue Laceration
The most common priority for patients with
facial fractures is repair of soft-tissue
lacerations. Ideally these should be sutured
before too much oedema has occurred; that is
within 1-8 hours of injury
HISTORY AND LOCAL EXAMINATION