1. Management of traumatized patient
Maxillofacial trauma
Management of traumatized patient

2. Causes: △ Road traffic accident (RTA) 35-60%
Rowe and Killey 1968;
Vincent-Towned and Shepherd 1994
△ Fight and assault (interpersonal violence)
Most in economically prosperous countries
Beek and Merkx 1999
△ Sport and athletic injuries
△ Industrial accidents
△ Domestic injuries and falls

3. Incidence
Literatures reported different incidence in different parts of the WORLD and at different TIMES
√ 11% in RTA (Oikarinen and Lindqvist 1975)
Mandible (61%)
Maxilla (46%)
Zygoma (27%)
Nasal (19.5%)

4. Factors affecting the high/low incidence of maxillofacial trauma
Geography
Fight, gunshot and RTA in developed and developing countries respectively (Papavassiliou 1990, Champion et al 1997)
Social factors
Violence in urban states (Telfer et al 1991; Hussain et al 1994; Simpson & McLean 1995)
Alcohol and drugs
Yong men involved in RTA wile they are under alcohol or drug effects (Shepherd 1994)
Road traffic legislation
Seat belts have resulted in dramatic decrease in injury (Thomas 1990, as reflected in reduction in facial injury (Sabey et al 1977)
Season
Seasonal variation in temperature zones (summer and snow and ice in midwinter) of RTA, violence and sporting injuries (Hill et al 1998)

5. Assessment of traumatized patient
This should not concentrate on the most obvious injury but involve a rapid survey of the vital function to allow management priorities
5% of all deaths world wide are caused by trauma
This might be much higher in this country

6. Peaks of mortality First peak
Occurs within seconds of injury as a result of irreversible brain or major vascular damage
Second peak
Occurs between a few minutes after injury and about one hour later (golden hour)
Third peak
Occurs some days or weeks after injury as a result of multi-organ failure

7. Organization of trauma services
triage decisions are crucial in
determining individual patients survival
Pre-hospital care (field triage)
Care delivered by fully trained paramedic in maintaining airway, controlling cervical spine, securing intravenous and initiating fluid resuscitation
Hospital care (inter-hospital triage)
Senior medical staff organized team to ensure that medical resources are deployed to maximum overall benefit
Mass casualty triage

8. Primary survey Ⓐ Airway maintenance with cervical spine control
Ⓑ Breathing and ventilation
Ⓒ Circulation with hemorrhage control
Ⓓ Disability assessment of neurological status
Ⓔ Exposure and complete examination of the patient

9. Airway
Satisfactory airway signifies the implication of breathing and ventilation and cerebral function
Management of maxillofacial trauma is an integral part in securing an unobstructed airway
Immobilization in a natural position by a semi-rigid collar until damaged spine is excluded

10. Sequel of facial injury
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

11. Immediate treatment of airway obstruction in facial injured patient
△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

12. Additional methods in preservation of the airway in patient with severe facial injuries
Endotracheal intubation
Needed with multiple injuries, extensive soft tissue destruction and for serious injury that require artificial ventilation
Tracheostomy
Surgical establishment of an opening into the trachea
Indications: 1. when prolonged artificial ventilation is necessary
2. to facilitate anesthesia for surgical repair in certain cases
3. to ensure a safe postoperative recovery after extensive surgery
4. following obstruction of the airway from laryngeal edema
5. in case of serious hemorrhage in the airway
Circothyroidectomy
An old technique associated with the risk of subglottic stenosis development particularly in children. The use of percutaneous dilational treachestomy (PDT) in MFS is advocated by Ward Booth et al (1989) but it can be replaced with PDT.
Control of hemorrhage and Soft tissue laceration
Repair, ligation, reduction of fracture and Postnasal pack

13. Cervical spine injury
Can be deadly if it involved the odontoid process of the axis bone of the axis vertebra
If the injury above the clavicle bone, clavicle collar should minimize the risk of any deterioration

14. Breathing and ventilation
Chest injuries:
Pneumothorax, haemopneumothorax, flail segments, reputure daiphram, cardiac tamponade
signs
Clinical
Deviated trachea
Absence of breath
sounds
Dullness to percussion
Paradoxical movements
Hyper-response with
a large pneumothorax
Muffled heart sounds
Radiographical
Loss of lung marking
Deviation of trachea
Raised hemi-diaphragm
Fluid levels
Fracture of ribs

15. Emergency treatment in case of chest injury
Occluding of open chest wounds
Endotreacheal intubation for unstable flail chest
Intermittent positive pressure ventilation
Needle decompression of the pericardium
Decompression of gastric dilation and aspiration of stomach content

16. Circulation
Circulatory collapse leads to low blood pressure, increasing pulse rate and diminished capillary filling at the periphery
Patient resuscitation
Restoration of cardio-respiratory function
Shock management
Replacement of lost fluid

17. Fluid for resuscitation: ☞Adequate venous access at two points
☞ Hypotension assumed to be due to hypovolaemia
☞ 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

18. Reduction and fixation will often arrest bleeding of long duration
Pulse and blood pressure should be monitored and appropriate replacement therapy is to be started

19. Neurological deficient
Rapid assessment of neurological disability is made by noting the patient response on four points scale:
A Response appropriately, is Aware
V Response to verbal stimuli
P Response to painful stimuli
U Does not responds, Unconscious

20. Glasgow coma scale (GCS) (Teasdale and Jennett, 1974)
Eye opening
Motor response
Verbal response
Spontaneous 4
Move to command 6
Converse 5
To speech 3
Localizes to pain
Confused
To pain 2
Withdraw from pain
Gibberish
none 1
flexes
grunts
Extends
Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15

21. Exposure
All trauma patient must be fully exposed in a warm environment to disclose any other hidden injuries
When the airway is adequately secured the second survey of the whole body is to be carried out for:
Accurate diagnosis
Maintenance of a stable state
Determination of priorities in treatment
Appropriate specialist referral

22. Secondary survey Although maxillofacial injuries is part of the secondary survey, OMFS might be involved at early stage if the airway is compromised by direct facial trauma
Head injury
Abdominal injury
Injury to extremities

23. Head injury Many of facial injury patients sustain head injury in particular the mid face injuries
Open
Closed
it is ranged from Mild concussion to brain death

24. Signs and symptoms of head injury
Loss of conscious OR
History of loss of conscious
History of vomiting
Change in pulse rate, blood pressure and pupil reaction to light in association with increased intracranial pressure
Assessment of head injury (behavioral responses “motor and verbal responses” and eye opening)
Skull fracture
Skull base fracture (battle’s sign)
Temporal/ frontal bone fracture
Naso-orbital ethmoidal fracture

25. slow reaction and fixation of dilated pupil denotes a rise in intra-cranial pressure
Rise in intercranial pressure as a result of acute subdural or extradural hemorrhage deteriorate the patient’s neurological status
Apparently stable patient with suspicion of head injury must be monitored at intervals up to one hour for 24 hour after the trauma

26. Acute bleeding may lead to hemorrhagic shock and circulatory collapse
Hemorrhage
Acute bleeding may lead to hemorrhagic shock and circulatory collapse
Abdominal and pelvis injury; liver and internal organs injury (peritonism)
Fracture of the extremities (femur)

27. Abdomen and pelvis
In addition to direct injuries, loss of circulating blood into peritoneal cavity or retroperitonial space is life threatening, indicated by physical signs and palpation, percussion and auscultation
Management:
Diagnostic peritoneal lavage (DPL) to detect blood, bowel content, urine
Emergency laprotomy

28. Extremity trauma
Fracture of extremities in particular the femur can be a significant cause of occult blood loss. Straightening and reduction of gross deformity is part of circulation control
Cardinal features of extremities injury
Impaired distal perfusion (risk of ischemia)
Compartment syndrome (limb loss)
Traumatic amputation

29. Patient hospitalization and determination of priorities Facial bone fracture is hardly ever an urgent procedure, simple and minor injury of ambulant patient may occasionally mask a serious injury that eventually ended the patient’s life
△ emergency cases require instant admission
△ conditions that may progress to emergency
△ cases with no urgency

30. Preliminary treatment in complex facial injury
Soft tissue laceration (8 hours of injury with no delay beyond 24 hours)
Support of the bone fragments
Injury to the eye
As a result of trauma, 1.6 million are blind, 2.3 million are suffering serious bilateral visual impairment and 19 million with unilateral loss of sight (Macewen 1999)
Ocular damage
Reduction in visual acuity
Eyelid injury

31. Prevention of infection Fractures of jaw involving teeth bearing areas are compound in nature and midface fracture may go high, leading to CSF leaks (rhinorrhoea, otorrhoea) and risk of meningitis, and in case of perforation of cartilaginous auditory canal
Diagnosis:
Laboratory investigation, CT and MRI scan
Management:
Dressing of external wounds
Closure of open wounds
Reposition and immobilization of the fractures
Repair of the dura matter
Antibacterial prophylaxis (as part of the general management (Eljamal, 1993)

32. Control of pain Displaced fracture may cause severe pain but strong analgesic ( Morphine and its derivatives) must be avoided as they depress cough reflex, constrict pupils as they may mask the signs of increasing intracranial pressure
Management:
☞ Non-steroidal anti-inflammatory drugs can be prescribed (Diclofenac acid)
☞ Reduction of fracture
☞ sedation

33. 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