Lec.1 General Management of The Patient With Facial Injuries

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General Management of the

Patient with Facial. Injuries

• Maxillofacial trauma can involve any part of


the face and it can have serious effects on
both the function and esthetics of the face.
Causes
The incidence of maxillofacial trauma varies from country to
country
• Road traffic accident (RTA):the most frequent causes of
facial fractures all over the world.
• Fight and assault (interpersonal violence)
• Sport and athletic injuries
• Industrial accidents
• Domestic injuries and falls
• Gunshot or missile injuries; this type of injury usually
cause complex pattern of trauma characterized by bone
and soft tissue loss and comminuted fractures of the
facial bones.
Assessment of traumatized patient
Triage : a process for sorting injured patients into
groups based on their need for likely benefit from
immediate medical management. It applied in hospital
emergency room when limited medical resource
available
Triaging of facial injuries:
1. Within a few seconds: immediate life or sight saving
intervention
2. Within a few hours: Clinically urgent injuries,
contaminated open #
3. Within a few days: compound #
4. Within a week: simple or closed #
Mortality from maxillofacial trauma

• First peak

Occurs within seconds of injury as a result of severe injury to the brain


and major cardiovascular structures, such as the heart and great vessels.

• 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.

The steps in the ATLS philosophy


■ Primary survey with simultaneous resuscitation –
identify And treat what is killing the patient(ABCDE rapid
assessment)
■ Secondary survey – proceed to identify all other injuries
(: head to toe examination)
■ Definitive care – develop a definitive management plan
Primary survey: immediate treatment
✓ Airway with cervical spine control
✓ Breathing and ventilation
✓ Circulation and hemorrhage control
✓ Disability due to neurological deficit
✓ Exposure and environment control
✓ Frequent Reassessment must be made
Airway with cervical spine control

All patients who have been subjected to maxillofacial


or head trauma should be presumed to have
sustained a cervical spine injury until proven
otherwise. The consequences of cervical spine
damage can be so catastrophic that every effort
should be made to prevent any further harm to the
patient; therefore the cervical spine should be
immobilized in the neutral position by means of a
semirigid cervical collar or spinal board until
definitive radiographs showing all seven cervical
vertebrae and the first thoracic vertebra are taken to
rule out cervical injury.
The provision of an unobstructed airway is of
prime importance in order to maintain cerebral
oxygenation and to avoid hypercarbia with
subsequent possible permanent cerebral impairment.
The most important factor controlling the patency of
the airway in a patient with facial injuries is the level
of consciousness.
A fully conscious and upright patient is usually
able to maintain an adequate airway even with the
presence of severe disruption of the facial skeleton.
However, a semi- or unconscious patient will
rapidly obstruct from the presence of blood and
mucus in the airway, inability to cough or inability to
adopt a posture to keep the airway clear. Progressive
swelling will compound all these problems.
Airway and cervical spine control

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.
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Airway and cervical spine control
△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 patient’s lips and continuous supervision


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Several techniques exist to provide an unobstructed
airway; these should be adopted in a logical
stepwise manner:

•Chin lift and jaw thrust help improve the airway,


but may be difficult to do in a conscious patient with
mandibular fractures.

•Jaw thrust involves placing the fingers behind the


angle of the mandible to push the jaw forwards and
upwards while the thumbs push down on the chin
or lower lip to open the mouth.
Chin lift
•A careful examination of the oral cavity should be
made, any dentures or portions of broken dentures
should be removed together with any avulsed teeth,
or loose or broken teeth that are so mobile there is a
risk of their being inhaled in addition to suction of
secretions, blood and mucus to clear the airway.

•Insertion of oropharyngeal or nasopharyngeal


airway can secure the airway, but they are not well
tolerated by conscious patients due to stimulation of
gag reflex. Nasopharyngeal airways are considered to
be contraindicated if there is the possibility of
anterior skull base fractures.
•Patients immobilized on a spinal board who vomit
are in danger of aspiration as they cannot sit up to
clear their airway. If such a patient is about to
vomit they should be immediately turned on their
side on the spinal board.

•Temporary reduction and stabilization of anterior


mandibular fractures with a (stay or bridle wire)
around stable teeth on either side of the fracture if
possible can reduce bleeding and support the
mandible.
•Endotracheal intubation is necessary to secure
airway if the patient has more severe damage,
cannot maintain the airway, requires ventilation,
when significant swelling is anticipated or in
patients with multiple injuries with combined
trauma to the head, face and chest.

•Emergency surgical airway is required when the


airway cannot be secured by any other means.
Surgical airway is obtained by cricothyroidotomy
(also known as cricothyrotomy) or tracheostomy.
Cricothyroidotomy is the fastest and safest method of
obtaining a surgical airway. Needle cricothyroidotomy
is a temporary procedure that is used to oxygenate
patients (for approximately 45 minutes) while a
definitive airway is being quickly prepared, in this
procedure a cannula is introduced into the lumen of
the trachea through the cricothyroid membrane to
deliver oxygen.
In surgical cricothytoidotomy the cricothyroid
membrane, which is usually superficial and palpable,
is perforated with a scalpel blade. A standard
tracheostomy tube can then be inserted and
maintained in the usual manner. Some surgeons prefer
to replace a cricothyroidotomy with a tracheostomy
within 24 hours. This is because cricothyroidotomy has
been reported to be associated with a higher risk of
glottis and subglottic stenosis than tracheostomies.
Surgical tracheostomy; an incision is made halfway
between cricoid cartilage and suprasternal notch,
dissection continues down to the 2nd and 3rd tracheal
rings, then a window is excised through the trachea and
the tracheostomy tube is inserted and secured.
Indications for tracheostomy in maxillofacial
injuries

1. When prolonged artificial ventilation is necessary


(for example, associated head and chest injuries).
2. To facilitate general anesthesia during surgical
repair of complex facial injuries.
3. To ensure a safe postoperative recovery after
extensive surgery.
4. Following obstruction of the airway from laryngeal
edema or occasionally direct injury to the base of the
tongue and oropharynx.
5. Following serious hemorrhage into the airway,
particularly when a further secondary hemorrhage is
a possibility.
Breathing and ventilation

• the efficiency of breathing and ventilation must be


assessed by auscultation ,chest radiographs, and
respiratory rate .
• Serious chest injuries that compromise ventilation are:

Pneumothorax which develops from damage to the chest wall


or laceration of the lung pleura, with a resulting loss of negative
intrapleural pressure, it can be: open, closed or tension
pneumothorax.
Hemothorax is the collection of blood in the pleural cavity.
Hemopneumothorax (which is hemothorax + pneumothorax)

The emergency treatment of the majority of these conditions


requires thoracostomy drainage with chest tube placed in the
fourth intercostal space anterior to the midaxillary line.
• Flail chest occurs when three or more adjacent ribs are
fractured in at least two locations, resulting in a freely
moving segment of chest wall during respirations.
(Endotreacheal intubation for unstable flail chest).

• Diaphragmatic rupture may result in herniation of


intraabdominal contents into the chest. This herniation
results in compression of the lung and displacement of
the mediastinum to the contralateral side, followed by
marked respiratory distress, cyanosis, and hypotension.

• Breathing problems may also arise following aspiration of


teeth, dentures, vomit and other foreign materials. In this
case endoscopy may be necessary to remove denture
fragments or other foreign bodies.
Circulation and hemorrhage control

Definitive bleeding control is essential, along with


appropriate replacement of intravascular volume. The
majority of fractures of the facial skeleton are relatively
closed injuries and life-threatening hemorrhage is
uncommon and hemorrhagic shock is unusual but clinically
significant blood loss can occur in patients with panfacial
fractures. Blood loss in young children can quickly result in
hypovolemia.
The parameters reflecting the degree of hypovolemic
shock are:

✓ 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 :

• direct manual pressure on the wound or by suturing.


• Obvious bleeding vessels should be secured with artery
forceps, ligated if possible.
• manual reduction of the fracture and temporary
immobilization either manually, or by means of a stay
wire.
• Epistaxis occurs stops spontaneously or is easily
controlled by lightly packing the nose (anterior nasal
packing). Packs should be kept in situ for 24-48 hours
• profuse bleeding into the nasopharynx may
occur, in such cases postnasal pack is needed,
• ligation of the vessels like the external carotid
artery and ethmoidal arteries, but these
measures can be unsuccessful due to the
collateral circulation.
• Superselective embolization involves catheter-
guided angiography used to identify bleeding
points then using of a number of materials
designed to stimulate clotting locally.
Penetrating neck trauma from sharp injuries can
cause internal bleeding from damage to the great
vessels without signs of external hemorrhage. This
is potentially serious, as the consequences of rapid
neck swelling can be fatal. Patients showing signs
of neck swelling or patients who show signs of
hemodynamic instability should have protection of
the airway and control of hemorrhage. The major
areas of internal hemorrhage in patients with
multiple trauma are the chest, abdomen,
retroperitoneum, pelvis, and long bones.
Adequate intravenous access is essential; typically,
two large-bore peripheral venous catheters are
placed to administer fluid, blood, and plasma.
The resuscitation fluid can be crystalloid, colloid, or
blood, if crystalloid is used, it should be transfused in
the ratio of 3 mL of crystalloid to 1 mL blood; an
appropriate initial bolus in an adult patient would be
2000 mL transfused as quickly as possible (or 20
mL/kg in the child). The response of the patient can
be assessed, and further fluid can be transfused
depending on the patient's response. In some cases
of surgical shock group 0 negative blood transfusion
can be used until type-specific blood is made
available.
• Urine output is a sensitive indicator of cardiac
output. Therefore, placement of a urinary
catheter is essential in all significant trauma
patients. Urine output levels below 0.5 mL/kg
body weight per hour for an adult, 1 mL/kg
body weight per hour for a child and 2 mL/kg
body weight per hour for a child younger than 1
year old suggest inadequate fluid replacement.
• Fluid for resuscitation:
☞Adequate venous access at two points
☞ 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

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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

Rapid assessment of neurological disability is made by noting the patient


response on four points scale: AVPU

• A Response appropriately, is Aware


• V Response to verbal stimuli
• P Response to painful stimuli
• U Does not responds, Unconscious

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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)

Eye Motor Verbal


opening response response
Spontaneous 4 Move to 6 Converse 5
command
To speech 3 Localizes to 5 Confused 4
pain
To pain 2 Withdraw 4 Gibberish 3
from pain
none 1 flexes 3 grunts 2
Extends 2
none 1
none 1

Score 8 or less indicates poor prognosis, moderate head injury


between 9-12 and mild refereed to 13-15
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Exposure and environment control

• All trauma patients must be fully exposed. Therefore


the environment must be warm and appropriately
protected to ensure that the patient suffers no
further harm by being exposed to the surrounding
ambient temperature. The patient should be fully
examined including an examination of the back, if
necessary, by using a logroll technique to ensure that
otherwise hidden areas have been inspected.
Secondary survey
After the operator has established a satisfactory
airway and controlled-hemorrhage, a full
examination of the patient should be carried out.

This head-to-toe examination involves examination


of all body systems. is to be carried out for:

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

History of the injury and, description of the


patient's symptoms:

➢Retrograde amnesia is failure to remember up


to the time of injury
➢anterograde amnesia is loss of memory
following the accident, both are indicative of
cerebral damage.
Local Clinical Examination of the Facial injury
patients face is gently washed with warm water
and cotton—wool swabs to remove caked
blood. The congealed blood in the palate and
buccal sulcus can be removed with cotton wool
held in untoothed forceps.
CONTROL OF PAIN avoid giving powerful analgesics
(morphine) which:

➢ Depress the level of consciousness and '


respiration.

➢ Depresses the couch reflex and so encourage the


aspiration of blood into the trachea.

➢ It causes constriction of the pupil (meiosis), which


may mask an early sign of the rise in intracranial
pressure (as in cerebral hemorrhage)

➢ Masks pain which may be due to intra—abdominal


or infra-thoracic injuries.
The most useful drug for sedation in such cases is
Diazepam (Valium) given intravenously_ Only
about 10mg are usually necessary
CONTROL OF INFECTION
Antibiotic should be given for five days

penicillin does not pass into the CSF in adequate


therapeutic concentration
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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