BDS10021 Maxillofacial Trauma 1 PDF

BDS10021 Maxillofacial Trauma 1 Aim: • The aim of this lecture is to detail the principles of the clinical diagnosis and treatment planning of maxillofacial trauma Objectives: • Understand the protocols for the diagnosis of maxillofacial injuries • Appreciate the importance of planning of initi...

BDS10021 Maxillofacial Trauma 1 Aim: • The aim of this lecture is to detail the principles of the clinical diagnosis and treatment planning of maxillofacial trauma Objectives: • Understand the protocols for the diagnosis of maxillofacial injuries • Appreciate the importance of planning of initial management of patients prior to definitive surgical interventions • Understand the importance and relevance of radiological investigation of maxillofacial injuries • Understand the multi-disciplinary approach to the early management of patients with maxillofacial injuries Mr SM have presented to the AC department with facial injury as a result of interpersonal violence Pre-op photographs Pre- op CT Intro-op: wound debridement Intra-op Post-op CT 3 weeks post-op 3 years post-op Nearly 25% to 33% of deaths caused by injury can be prevented when an organized and systematic approach is applied 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 Trauma Maxillofacial injuries ✓Incident occurred: How (mode of injury : Fall/ RTA / violence ,,,,) Where? When? ✓Loss of consciousness ✓Other injuries ✓Relevant Medical history Trauma Primary Survey : Manage life threatening conditions, 1. 2. 3. 4. 5. Airway maintenance Breathing Circulation (Hemorrhage control) Disability assessment & neurological control Exposure Airway How can you recognize airway obstruction??? LOOK, LISTEN , FEEL ? Silence ? Gurgling ? Snoring Airway How could you maintain the airway ? • Head tilt chin lift Vs Jaw thrust !!Always consider cervical spine injury Airway • Types of airway: • Oropharyngeal • Nasopharyngeal • How to decide size? • When to avoid nasopharyngeal airway? Airway • Endotracheal intubation only after cervical spine radiograph • Surgical airway intervention • Cricothyrotomy • Tracheostomy Breathing Is there any penetration chest injury, in doubt : CXR ?? Pneumothorax / hemothorax Management: one way valve / Chest tube Spontaneous ventilation is inadequate: Initiate ‘Artificial ventilation’ Circulation : Hemorrhage Control ‘’Always remember that maxillofacial injuries rarely cause hypovolemic shock’’ How to control hemorrhage ?? “pressure, pressure, pressure” !!Anterior and posterior nasal packs !!Bleeding from neck wound : surgical emergency !!Bleeding from a fractured maxilla?? Can’t be controlled except after Manual repositioning Disability assessment & neurological deficit Subarachnoid haemorrhage Intracerebral haemorrhage Subdural haemorrhage Disability assessment & neurological deficit ✓A- Responds appropriately & is Aware ✓V- Responds to Verbal stimuli ✓P- Responds to Painful stimuli ✓U- Unconscious, doesn’t respond Glasgow coma scale Eyes open Spontaneously 4 3 2 1 To speech To pain Do not open Best verbal response Orientated Confused Inappropriate Incomprehensible No verbal response 5 4 3 2 1 Best motor response Obeys commands 6 Localizes pain 5 withdraws to pain Abnormal flexion 4 3 Abnormal extension No motor response 2 1 Glasgow coma scale ✓Severe: Less than 8 ✓Moderate: 9-12 ✓Minor: 13-15 Other signs indicate neurological deficit: ✓Unequal pupils ✓Open head injury ✓Unilateral pupil dilatation. Other considerations • Tetanus immunity If in doubt give tetanus toxoid • Analgesia :Avoid opioids if possible as they interfere with neuroobservations by limiting pupillary response. • Teeth : if lost, ensure they are not in the chest (CXR) or soft tissues. Patients to admit • If in doubt admit. Place on, at least, initial hourly neurological observations (most will need 24-48 hourly observation initially) • Any question of danger to the airway • Skull # • History of unconsciousness • Retrograde amnesia • Bleeding • Middle 1/3 #, mandibular # (except when very simple), malar # if +ve eye signs, children, and those with domestic or social problems. • IV access and antibiotic. If not admitting, give the patient a head-injury card. Head injury requiring neurological referral When to refer ?? ✓Deterioration of the level of consciousness ✓Fractured skull with focal neurological signs ✓Suspected fracture base of skull?? ✓(Sign: CSF leak nose , ear , post.mx ) ✓Don’t miss cranial nerve examination… Cranial Nerves Examination Trauma Secondary survey: Objectives: ✓Accurate diagnosis of injuries ✓Maintenance of stable state ✓Treatment priorities ✓Multidisciplinary consultation and referral ?? Radiographic Examination ✓Skull and mandible ✓Cervical spine ✓Chest ✓Pelvis Just one more step… Radiographic assessment Best review for fractures is do 2 x-rays perpendicular on each other Panoramic xray (OPG) What do you see? Radiographic assessment Occipitomental radiograph (OM): ✓Sinus view ✓Le Fort l ✓Le fort ll ✓Le fort lll ✓Orbital blow out ✓Coronoid process fractures Radiographic assessment Posteroanterior of the jaws: ✓Posterior 1/3 of the body ✓Angle of the mandible ✓Ramus ✓Low condylar neck Radiographic assessment Reverse town’s: ✓High fractures of the condylar necks ✓Intra capsular fractures(TMJ) Radiographic assessment True lateral skull radiograph: ✓Fractures of cranial base ✓Middle 1/3 facial fractures ✓What else ??? Radiographic assessment Submentovertex (SMV): ✓Fractures of zygomatic arch ✓Destructive lesions affecting the palate ✓Mandible Indication for CT Scans in Maxillofacial Trauma CT scans are more precise but more hazardous in radiation exposure. • Best in the evaluation of the fracture fissures (orbital and NOE fractures, condylar fractures, pan facial fractures…..). • Three-dimensional reconstructions are a good complementary technique allowing to locate free bone fragments precisely and to assess the degree of their displacement. Bone fractures Aim of treatment: ✓Restore normal function & esthetics ✓Reduction (open,closed) ✓Fixation (Internal ,external) Complications: ✓Malunion ✓Delayed union ✓Non union ✓Fracture site infection Management ✓Antibiotics & analgesics ✓Reduction (open/closed) ??? ✓Fixation with immobilization of fx. Site ✓Functional rehabilitation Case A 42 yrs old male patient presented at the hospital shouting for help.. He was involved in a fight and had a trauma to his face.. He says his left eye is very painful & his vision has been deteriorated.. Describe the picture: What to do now? Always ask your patient CAN YOU SEE WELL? Retrobulbar haemorrhage: Arterial bleed behind the globe following trauma. It’s a surgical emergency. (Immediate surgical decompression to prevent blindness) Medical management mannitol 20 % 2 g/kg IV acetazolamide 500 mg IV dexamethosone 1 mg/kg IV Soft tissue trauma Management.. ✓Tetanus prophylaxis ✓Antibiotics ✓Irrigation ✓Debridement ✓Hemostasis ✓Primary closure to minimize scarring • Reading material: • Wray D et al; Textbook of General and Oral Surgery, Churchill Livingstone 2003 pp 89-102 • Kerawala C, Newlands C. Oral and Maxillofacial Surgery. Oxford University Press, 2010 pp 1-61 • Brennan et al. Maxillofacial Surgery Volume 1. Elsevier 2017 pp 3-37 TO SUM IT UP : • Diagnosis of facial trauma is part of a pan management of trauma patient (maybe it not the most important trauma) • Aim of Trauma Primary Survey is to save and stabilise patient condition • Aim of Secondary Servery is accurate diagnosis and planning priorities • Choice of diagnostic X-rays shall be made on patient specific bases not generic for all patients • Team work is how you will save your patient , practice it! Aim: • The aim of this lecture is to detail the principles of the clinical diagnosis and treatment planning of maxillofacial trauma Objectives: • Understand the protocols for the diagnosis of maxillofacial injuries • Appreciate the importance of planning of initial management of patients prior to definitive surgical interventions • Understand the importance and relevance of radiological investigation of maxillofacial injuries • Understand the multi-disciplinary approach to the early management of patients with maxillofacial injuries Thank you