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Lec

By Dr. Badr Ibdaa

Maxillofacial Trauma
Introduction

Maxillofacial trauma can involve any part of the face and it can
have serious effects on both the function and esthetics of the
face.

The incidence of maxillofacial trauma varies from country to

country (and even within the same country), depending on
several factors, including the geographic area, the
socioeconomic status, the cultural background, alcohol and drug
abuse, road traffic legislations and seasons.

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Etiology

The etiology of maxillofacial trauma directly affects the incidence,

the clinical presentation, and the treatment modalities.

The main causes include:

1. Road traffic accidents (RTA); also termed motor vehicle

collisions, are still among the most frequent causes of facial
fractures all over the world.

2. Assaults and interpersonal violence; the face is frequently

the target for most acts of physical aggression because of
its prominent and easily reachable position.
3. Assault-related fractures tend to affect males and young
people due to their greater involvement in situations of
violence.

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Etiology

The main causes include:

3. Fall; is a relatively frequent cause, the height of the fall, the

landing position, the location of contact, and the impact
surface determine the pattern and severity of maxillofacial
trauma.

4. Sport-related injuries; the mechanisms of injury can be

divided into three categories: impact with another individual,
impact with the ground, and impact with equipment.
It usually affects young people who participate more in sports
than older people.

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Preliminary management of maxillofacial injuries

Mortality from trauma has a trimodal distribution with three

clearly defined peaks:

1. The First Peak in mortality is within seconds or minutes of

Death
the event, when the degree of injury received is the most
severe such as severe injury to the brain and the major
cardiovascular structures, such as the heart and great vessels.

2. The Second Peak occurs some minutes to 1 or more hours

after the event. Death is attributed to unrecognized serious
complications, such as airway compromise, hemorrhage, and
head injury.
• The golden hour of care after injury is characterized by the
need for rapid assessment and resuscitation.

3. The Third Peak occurs days to weeks after the event, when
sepsis or multi-organ failure occur and lead to death

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Preliminary management of maxillofacial injuries

Prehospital care involves delivering active professional intervention and

emergency measures at the scene of the event by trained paramedical
personnel.

This Active Prehospital Care Encompasses:

▪ Securing an airway with appropriate cervical spine control

▪ Securing appropriate intravenous access and initiating fluid

resuscitation

▪ Stabilizing the patient before rapid transfer to an emergency

department.

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Primary survey

During the primary survey, life-threatening conditions are

identified and reversed quickly.

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 Principles Of ATLS Are:

A. Airway with cervical spine control
B. Breathing and ventilation
C. Circulation and hemorrhage control ABCDE
D. Disability due to neurological deficit
E. Exposure and environment control + Eye

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A Airway and 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.

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A Airway and cervical spine control

Normal
7+1

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A Airway and cervical spine control

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 patient is usually able to maintain an adequate airway

even in the presence of severe disruption of the facial skeleton.

▪ However, in a semi- or unconscious patient the airway will be rapidly

obstructed 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.

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A Airway and cervical spine control

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 Jaw thrust

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A Airway and cervical spine control

Several techniques exist to provide an unobstructed airway;

these should be adopted in a logical stepwise manner:

▪ 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.

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A Airway and cervical spine control

Several techniques exist to provide an unobstructed airway;

these should be adopted in a logical stepwise manner:

▪ 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.

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A Airway and cervical spine control

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A Airway and cervical spine control

Several techniques exist to provide an unobstructed airway;

these should be adopted in a logical stepwise manner:

▪ 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.

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A Airway and cervical spine control

Several techniques exist to provide an unobstructed airway;

these should be adopted in a logical stepwise manner:

▪ Collapsed maxillary fractures may cause airway

obstruction. It can be displaced backwards and downwards
along the inclined surface of the relatively thick skull base,
resulting in impaction of the soft palate into the pharyngeal
space.
▪ The maxilla should be gently repositioned to maintain the
airway and control hemorrhage.

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 A Airway and cervical spine control

Several techniques exist to provide an unobstructed airway;

these should be adopted in a logical stepwise manner:

▪ Endotracheal intubation is necessary to secure airway if the

patient has:
Indic ✓ More severe damage,
✓ Cannot maintain the airway,
✓ Requires ventilation,
✓ When significant swelling is anticipated
✓ In patients with multiple injuries with combined trauma
to the head, face and chest.

Indic ▪ Emergency surgical airway is required when the airway cannot

be secured by any other means. Surgical airway is obtained
by: A- cricothyroidotomy (also known as cricothyrotomy) or
B- tracheostomy.

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A Airway and cervical spine control

A- 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 cricothyroidotomy 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.

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A Airway and cervical spine control

B- 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.
suprasternal
notch
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.

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B Breathing and ventilation

Once airway is secured, the efficiency of breathing and ventilation must be

assessed by auscultation and chest radiographs. The respiratory rate
should also be determined.

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.

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B Breathing and ventilation

Pneumo, Hemo, Hemopneumo

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.

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 B Breathing and ventilation

Serious chest injuries that compromise ventilation are:

▪ 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.

▪ 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.

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 C 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.

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 C Circulation and hemorrhage control

The parameters reflecting the degree of hypovolemia are:

✓ Tachycardia; defined as heart rate greater than 100 beats/min in an adult.
✓ Hypotension
✓ “Narrowing” pulse pressure (systolic minus diastolic)
✓ Tachypnea
✓ Delayed capillary return
✓ Falling urinary output
✓ Deteriorating mental status (i.e., increasing confusion)

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C Circulation and hemorrhage control

Bleeding control:
The source of bleeding can be external or internal, bleeding can
occur from external wounds, such as the scalp which can be
controlled by direct manual pressure on the wound or by
suturing.

Obvious bleeding vessels should be secured with artery forceps,

ligated if possible.

Another source of bleeding can occur from grossly displaced

fracture of the mandible or midface, this can be controlled by
manual reduction of the fracture and temporary immobilization
either manually, or by means of a stay wire.

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C Circulation and hemorrhage control

Bleeding control:
Epistaxis occurs due to injury to the middle third of the face, it
usually stops spontaneously or is easily controlled by lightly
packing the nose (anterior nasal packing).

In some cases profuse bleeding into the nasopharynx may occur,

in such cases postnasal pack is needed, specifically designed nasal
balloons or packs are used or two urinary catheters can be used.
Each is passed via both nostrils into the pharynx, inflated with
saline and then gently withdrawn until the balloon wedges in the
post-nasal space.

Packs should be kept in situ for 24-48 hours.

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C Circulation and hemorrhage control

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C Circulation and hemorrhage control

Bleeding control:
Additional uncommon bleeding control measures include; 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.

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C Circulation and hemorrhage control

Bleeding control:
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.

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C Circulation and hemorrhage control

Replacement of intravascular volume:

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 O negative blood

transfusion can be used until type-specific blood is made available.

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C Circulation and hemorrhage control

Replacement of intravascular volume:

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.

Adult Child Child younger

than 1 year

0.5 mL/Kg 1 mL/Kg 2 mL/Kg

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 D Disability due to neurological deficit

A Rapid Assessment of the patient’s neurological disability can

be made by noting the patient’s response on the four-point
AVPU scale:

✓ A Alert.
✓ V Voice, able to respond to verbal command.
✓ P respond to painful stimuli.
✓ U Unresponsive.

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 D Disability due to neurological deficit

AVPU scale
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.

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E 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.

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 Secondary survey

It is important at all stages of the management of the trauma victim that reassessment is
regularly carried out to ensure that the patient is still stable and to detect any early
deterioration.
This head-to-toe examination involves examination of all body systems. Once the patient is
stabilized and after adequate resuscitation a detailed assessment of the level of head
injury is made using a combination of the pupil reactions and the Glasgow Coma Scale.
Glasgow coma scale:
It is a method of neurological assessment of the level of consciousness; it provides a Lowest Highest
reliable, objective way of recording the conscious state of a patient. score score
It can be used for initial evaluation as well as regularly recording improving or
deteriorating status. 3 15
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
Bellow 8
their airway.
Intubate
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Secondary survey

Glasgow coma scale:

Best eye response (E) Best verbal response (V)
Consists of 4 grades starting with the most severe: Consists of 5 grades, starting with the most severe:
1. No eye opening. 1. No verbal response.
2. Eye opening in response to painful stimulus. 2. Incomprehensible sounds.
3. Eye opening in response to command. 3. Inappropriate words.
4. Spontaneous eye opening. 4. Confused conversation.
5. Orientated; coherent and appropriate response to
questions.

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 Secondary survey

Glasgow coma scale:

Best motor response (M)

Consists of 6 grades, starting with the most severe:
1. Makes no movements.
2. Abnormal extension (decerebrate posture).
3. Abnormal flexion (decorticate posture).
4. Flexion/withdrawal to pain.
5. Localizes to pain.
6. Obeys commands.

**No score 0

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 Secondary survey

Vision threatening injuries:

These include:
1. Orbital compartment syndrome and retrobulbar hemorrhage.
2. Traumatic optic neuropathy.
3. Open and closed globe injuries.
4. Loss of eyelid integrity.

Once the patient is stabilized early recognition of vision threatening injuries is essential.

The initial assessment examines vision in each eye, pupil size and reaction to light, presence of
proptosis and eyelid integrity.

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