Maxillofacial Trauma

Initial Management of the Trauma Patient

The initial assessment and management of a patient’s injuries must be completed in an accurate and systematic manner to quickly establish the extent of any injury to vital life-support systems. About

30 % of deaths caused by injury can be prevented when an organized and systematic approach is used

Death from trauma is within seconds or minutes of the injury due to;

1. 1. lacerations of the brain,

2. brainstem,

3. upper spinal cord,

4. heart,

5. aorta, or

6. other large vessels.

First few hours after injury (calls golden hours) is also important for life saving. Death is usually due to;

1. 1. central nervous system (CNS) injury

2. hemorrhage.

Sepsis, multiple organ failure, or pulmonary embolism is another reason of death within days or weeks.

Patients are assessed and treatment priorities are established based on patients’ injuries and the stability of their vital signs. Injuries can be divided into three general categories:

1. severe (airway, inadequate breathing ,hemorrhage, and circulatory system damage or shock)

2. urgent (injuries to the abdomen, orofacial structures, chest, or extremities) and

3. nonurgent (nonurgent injuries account for approximately 80% of all injuries)

Glasgow Coma Scale

Scores range from 3 to 15, with a higher number representing an increased degree of consciousness. Patients with a head injury who had an admission GCS of 9 or less correlated with higher mortality rates.

Action Score

Eye opening

Spontaneously 4

To speech 3

To pain 2

None 1

Motor response

Obeys 6

Localizes pain 5

Withdraws from pain 4

Flexion to pain 3

Extension to pain 2

None 1

Verbal response

Oriented 5

Confused 4

Inappropriate 3

Incomprehensible 2

None 1

15 = normal; 13 or 14 = mild injury; 9–12 =moderate injury; 3–8 = severe injury.

Table 18-2 Revised Trauma Score Variables

ABC(DE)

During the primary survey, life-threatening conditions are identified and reversed quickly. The primary survey progresses in a logical manner based on the ABCs: Airway maintenance with cervical spine control, Breathing and adequate ventilation, and Circulation with control of hemorrhage. Degree of consciousness, and Exposure of the patient via complete undressing to avoid injuries being missed .

Airway

In the trauma patient, upper airway obstruction may be due to

1. bleeding from oral or facial structures,

2. aspiration of foreign materials, or

3. regurgitation of stomach contents.

Commonly, the upper airway is obstructed by the position of the tongue, especially in the unconscious patient . Initially a chin-lift or jaw-thrust procedure may position the tongue and open the airway. This method should not hyperextend the neck. The other hand can be used to assist with access to the oral cavity, using the fingers in a sweeping motion to remove such things as debris, vomitus, blood, and dentures that may be responsible for the obstruction. Maintenance of the cervical spine in the neutral position is best achieved with the use of a backboard, bindings, and purpose-built head immobilizers. The use of soft or semirigid collars allows, at best, only

50% stabilization of movement.

Table 18-4 Mortality Rates for Various Injury Severity Scores by Age Groups

Breathing

With establishment of an adequate airway, the pulmonary status must be evaluated. If the patient is breathing spontaneously confirmed by feeling and listening for air movement at the nostrils and mouth supplemental oxygen may be delivered by face mask. The exchange of air does not guarantee adequate ventilation. The chest wall of a patient with a pneumothorax, flail chest, or hemothorax may move but not ventilate effectively. Also, shallow breaths with minimal tidal volumes do not ventilate the lungs effectively. Very slow or rapid rates of respiration usually suggest poor ventilation. The patient’s status should be reevaluated constantly. If signs of adequate ventilation deteriorate, a secure airway should be placed (ideally an endotracheal tube) and assisted ventilation should be started. The rate of breathing should be evaluated for tachypnea or other abnormal breathing patterns. Arterial oxygen tension (PaO2) should be maintained between 70 and 100 mm Hg.

Circulation

Following establishment of an adequate airway and breathing in the injured patient, the cardiovascular system of the patient must be assessed and control of baseline circulation to the tissues must be quickly restored. The most common cause of shock in the traumatized patient is hypovolemia caused by hemorrhage (externally or internally).Decreased intravascular volume is immediately reflected in decreased urinary output. Any patient with significant trauma should always have an indwelling urinary catheter inserted to monitor urine volume every 15 minutes. A minimally adequate urine output is 0.5 mL/kg/h, and fluid therapy should be initiated to maintain at least this level of urinary output. If the patient’s injuries include pelvic fractures or blunt trauma to the groin, a urinary catheter should not be placed until a urethrogram can be evaluated for urethral injury.

Control of Bleeding: Hemorrhage is defined as an acute loss of circulating blood. Normally the blood volume is approximately 7% of the adult ideal body weight and in children the blood volume is usually between 8 and 9% of body weight (80–90 mL/kg). Bleeding may be external or internal into body cavities. Most external hemorrhage can be controlled with direct pressure to the wound. If an extremity is involved, it should be elevated. Firm pressure should be continuous. Firm pressure on the major artery in the axilla, antecubital space, wrist, groin, popliteal space, or ankle may assist in control of hemorrhage distal to the site. Pressure bandages include the use of air-pillow splints and blood pressure cuffs. Scalp or skin wounds may best be managed with immediate closure with large monofilament sutures (without cosmetic closure considerations) and direct pressure until the hemorrhage is controlled. Because of the rich blood supply to the face and neck, significant hemorrhage may be associated with large scalp wounds, nasal or midface fractures, and penetrating neck wounds. In a short period of time the scalp may lose a large amount of blood, which oozes from the galea and loose connective tissue layers. The wound can be approximated rapidly with 2-0 nonresorbable sutures without regard to cosmetic closure. Direct pressure should then be placed over the wound to control the hemorrhage and minimize hematoma formation.

Nasal or midface fractures may hemorrhage from tears of the ethmoidal arteries that arise from the internal carotid system or from branches of the maxillary artery system . Most hemorrhages from facial injuries can be controlled with direct pressure or packing. Internal maxillary artery bleeding from posterior maxillary wall fractures associated with Le Fort I or II level fractures usually can be controlled by pressure with gauze packing for extended periods. Ligation of the external carotid artery may be required only in extreme cases; usually it is ineffective when used alone and without direct control of hemorrhage because of the collateral circulation of the face.Blood loss with fractures should be considered to be at least 1,000 to 2,000 mL for pelvic fractures, 500 to 1,000 mL for femur fractures, 250 to 500 mL for tibia or humerus fractures, and 125 to 250 mL for fractures of smaller bones. A hematoma the size of an apple usually contains at least 500 mL of blood.

Degree of Consciousness

A brief neurologic evaluation is performed to establish the patient’s level of consciousness and pupillary size and reaction. Be aware of any medications that the patient may have received or drugs he or she may have taken that may affect the pupils.

Exposure of the Patient

The patient should be completely disrobed so that all of the body can be visualized, palpated, and examined for injuries or bleeding sites. The clothing must be completely removed, even if the patient is secured to a spinal backboard.

Secondary Assessment

The secondary assessment includes a subjective and objective evaluation of the injured patient. A subjective assessment should include a brief interview with the patient, if possible. A brief health history can be useful, including medications; allergies; previous surgery; a history of the injury; and the location, duration, time frame, and intensity of the chief complaint.

Head and Skull

Primary injuries to the head and skull may involve

1. lacerations, abrasions, avulsions, and contusions of the scalp;

2. fractures of the cranium and cerebral contusions; and

3. intracranial bleeding to the brain from lacerations or shearing injuries.

The physical examination of the head should include an examination of the scalp for lacerations and foreign bodies. Because of the rich vascular supply of the scalp, especially in children, scalp injuries may result in significant blood loss.

Lacerations may overlie an injury to the cranium, or intracranial hemorrhage may be present. Whenever a basilar skull fracture is suspected, a nasogastric tube should not be used because the tube may inadvertently pass into the cranial vault.

Pupillary function, eye movements, and eye opening can provide information about the level of consciousness, as well as about brainstem function. The size, shape, and reactivity of the pupil to light provide information about second and third nerve function and midbrain activity. In normal activity, when light is shone in one eye, both pupils constrict equally. If a light is shone into the right eye and the left eye does not respond, there may be a disruption of the right optic or left oculomotor nerves. If the light is then shone into the left eye and it does not respond, a disruption of the third cranial nerve should be suspected. Pupillary dilatation of one eye may be due to a developing brain herniation on the ipsilateral side, with bilateral pupillary dilatation suggestive of significant midbrain injury or loss of parasympathetic function. Conversely, pinpoint pupils after head trauma may indicate drug overdose or loss of sympathetic tone as seen in Horner’s syndrome.

CSF emerging from the nose or ear is commonly associated with a basilar skull fracture. Clear or red-tinged fluid that drains from the nose or ear should be considered to be CSF. There is no reliable method available in the emergency department for distinguishing CSF from nasal mucosa. The use of glucose indicator sticks is associated with a high incidence of false-positive results. A useful aid may be a “ring sign.” A drop of the fluid from the nose or ear is placed on a piece of filter paper. If the fluid is CSF, the blood components of the fluid remain in the center and rings of clear fluid form around them.A CT scan should be performed to determine whether there is a fracture site. The head of the bed should be elevated to 90°.

Maxillofacial Area

Maxillofacial injuries may cause airway compromise from blood and secretions, from a mandibular fracture that allows the tongue to fall against the posterior wall of the pharynx, from a midface injury that causes the maxilla to fall down and back into the nasopharynx, and from foreign debris such as avulsed teeth or dentures. A large tonsillar suction tip should be used to clear the oral cavity and pharynx. An oral airway assists with tongue position; however, care must always be taken to avoid manipulation of the neck and to provide for access to the oral cavity and dentition for reduction and fixation of any fractures requiring some period of intermaxillary fixation.

The physical examination should begin with an evaluation for soft tissue injuries.