chap-3a Initial management of ocmfs trauma ATLS.pptx

Initial management of ocmfs trauma ATLS.pptx

1. Initial management in trauma patient By Dr.Alelign , OMFS R2 7/21/2024 OMFS 1 Approach to maxillofacial trauma

2. Outline 7/21/2024 OMFS 2 Learning objectives Introduction to Maxillofacial trauma ATLS protocols in Maxillofacial trauma Primary survey and resuscitation Secondary survey and definitive care Principle of management of Maxillofacial soft tissue injuries Principle of management of Maxillofacial fractures Take home message References

3. Learning objectives 7/21/2024 OMFS 3 Identify the correct sequence of priorities for the assessment and initial management of trauma patient Explain the principles of the primary survey, secondary survey and adjuncts as they apply to the assessment of an injured patient. Summarizes the general principles for management of Maxillofacial soft tissue injuries and fractures

4. Introduction to Maxillofacial Trauma 7/21/2024 OMFS 4 Facial trauma is a common and potentially life-threatening condition in ER Can result from various causes, such as motor vehicle accidents, falls, assaults, sports injuries, animal bites, and gunshot wounds The goals of treatment are Restore the function Appearance of the facial structures Prevent complications Improve the quality of life of the patient.

5. Introduction to Maxillofacial Trauma 7/21/2024 OMFS 5 The approach to facial trauma involves An initial history and physical examination Patient’s airway, breathing, circulation, disability and exposure, A thorough secondary examination The facial structures and whole body Imaging studies such as plain radiographs, CT or MRI, Helps to identify the extent and location of the fractures, soft tissue injuries, and associated injuries to other organs.

6. Introduction to Maxillofacial Trauma 7/21/2024 OMFS 6 The timing and technique of surgery depend on several factors, The stability of the patient, The degree of displacement or comminution of the fractures, The presence of infection or necrosis, and The availability of donor sites or implants

7. Introduction to Maxillofacial Trauma 7/21/2024 OMFS 7 The outcome of facial trauma is influenced by many factors, such as The mechanism and severity of injury, The age and comorbidities of the patient, The experience and skill of the surgeon, The quality and duration of follow-up care.

8. Introduction to Maxillofacial Trauma 7/21/2024 OMFS 8 The potential complications of facial trauma include Paresthesia, Anaesthesia Malunion & deformities Infection, delayed union and non-union Derangement of occlusion, Ankylosis of TMJ Eye problems: Diplopia, Enophthalmos, Strabismus and Epiphora Deviated nasal septum, nasal congestion Psychological distress.

9. Introduction to Maxillofacial Trauma 7/21/2024 OMFS 9 Acc to Peterson et., patient with a maxillofacial trauma has high risk of airway-related complications during the perioperative period 12% of complications arose at extubation and 5% during recovery. Important To defer extubation until the edema subsides To prevent nausea and vomiting, the risk of GI content aspiration, especially in MMF. In patients with a tracheotomy tube, the patient should be allowed to breathe spontaneously through the tracheostomy tube for a few days in order to ensure a safe recovery

10. Concepts of Initial Assessment 7/21/2024 OMFS 10 Preparation Triage Primary survey ( ABCDEs ) Resuscitation Adjuncts to primary survey and resuscitation Secondary survey ( head-to-toe evaluation and history ) Adjuncts to the secondary survey Continued post-resuscitation monitoring and reevaluation Definitive care

11. Triage and prioritization 7/21/2024 OMFS 11 Nearly 25–33% of deaths caused by injury can be prevented when an organized and systematic approach is used Death from trauma has a trimodal distribution

12. Triage and prioritization 7/21/2024 OMFS 12 The primary goal of triage is to prioritize victims according to the severity and urgency of their injuries and the availability of the required care

13. Assessment of the Severity of Injury 7/21/2024 OMFS 13 Trauma scoring systems are used to assess the severity of a patient’s injuries and predict their outcomes. Facilitate Interpretation of trauma literature Decipher operative reports Comprehend methods of predicting patient outcome Three main groups of trauma scores : Anatomical:- Injury severity score (ISS), New injury severity score (NISS), Physiological:- Revised trauma score (RTS), Acute physiology and chronic health evaluation (APACHE) Combined:- Trauma and Injury severity score (TRISS), International classification of diseases-based ISS (ICISS)

14. The Revised Trauma Score (RTS) 7/21/2024 OMFS 14 Is a commonly used physiological scoring system that takes into account the patient’s Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate. Provided a means of characterizing the physiologic status of injured patients’ cardiovascular, respiratory, and neurologic systems.

15. Injury Severity Score (ISS) 7/21/2024 OMFS 15 Provides an overall score for patients with multiple injuries and severity of the condition Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities (including Pelvis), External) Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score.

16. Injury Severity Score (ISS) 7/21/2024 OMFS 16

17. Advanced Trauma Life Support - ATLS 7/21/2024 OMFS 17 Developed by the American college of surgeons Philosophy of ATLS Treat the greatest threat to life first. Never allow the lack of definitive diagnosis to impede the application of an indicated treatment. A detailed history is not essential to begin the evaluation of a patient with acute injuries. Basic principles for preservation of life in a trauma patient Maintenance of patency of airway Bleeding control Maintenance of circulation

18. Advanced Trauma Life Support - ATLS 7/21/2024 OMFS 18 ATLS Protocol has 2 components Primary survey and resuscitation Quick examination of the patient to detect immediately life threating situations Develop measures to correct them Secondary survey and definitive care Done after life threating condition have been evaluated and resuscitation measures are instituted To identify all other injuries that will require treatment

19. Primary survey and Simultaneous Resuscitation 7/21/2024 OMFS 19 Elements of primary survey Airway and c-spine protection Breathing and ventilation Circulation with control of hemorrhage Dysfunction and neurological assessments Exposure

20. A- Airway and c-spine protection 7/21/2024 OMFS 20 First assess the airway to ascertain patency Clinical Signs and Symptoms of Airway Obstruction Initially there will be restlessness, apprehension, anxiety. Tachypnea, tachycardia, pallor. Rapid, labored breathing (gasping for breath). Rapid movement or fluttering of the alae of the nose. Crowing sound, stridor, intercostals retraction

21. A- Airway and c-spine protection 7/21/2024 OMFS 21 Acc to Hutchison et al., Six specific situations associated with facial trauma which can affect the airway: Posteroinferior displacement of a fractured maxilla may block the nasopharyngeal airway. A bilateral fracture of the anterior mandible may cause the tongue to slide posteriorly and block the oropharynx Fractured teeth, bone fragments, vomitus, blood, secretions and foreign bodies, such as dentures, debris, may block the airway anywhere along the oropharynx and larynx.

22. A- Airway and c-spine protection 7/21/2024 OMFS 22 Hemorrhage from distinct vessels in open wounds or severe nasal bleeding may also contribute to airway obstruction. Soft tissue swelling and edema may cause delayed airway compromise. Trauma of the larynx and trachea may cause swelling and displacement of structures, such as the epiglottis, arytenoid cartilages, and vocal cords, thereby increasing the risk of cervical airway obstruction.

23. A- Airway and c-spine protection 7/21/2024 OMFS 23 Acc to Haug et al., Patients with traumatic injuries to the Maxillofacial region are at high risk of cervical spine injury. Injuries to the midface are most associated with C5-7 disruption while Injuries to the lower face tend to be associated with C1-4 disruption. The cervical spinal cord injury occurs at the time of trauma in 85% of patients and as a late complication in 15%. The incidence of cervical spine injury associated with maxillofacial trauma varies from 0.3% to19.3%.

24. A- Airway and c-spine protection 7/21/2024 OMFS 24 C-spine Protection Until the C-spine is cleared radiologically and clinically, precautions must be made during the perioperative period. The patient must be fitted with a neck collar for cervical spine immobilization. Especially important during transport and positioning for surgery Is critical with regard to neurologic recovery or deterioration. Delayed recognition of an injury or improper stabilization of the cervical spine may lead to irreversible spinal cord injury and permanent neurologic damage

25. A- Airway and c-spine protection 7/21/2024 OMFS 25 The NEXUS Low-Risk Criteria  C-spine imaging is recommended for patients with trauma unless they meet all of the following criteria: NSAID Absence of focal neurological deficit Absence of posterior midline cervical-spine tenderness # A normal level of alertness and consciousness (baseline mental status) No evidence of intoxication, Absence of any distracting injuries

26. Managing the airway 7/21/2024 OMFS 26 Basic airway management Ventilatory assistance and O2 Supplement Position of the patient:- supine with neck extended head turned sideways. Chin-lift and Jaw thrust,

27. Managing the airway 7/21/2024 OMFS 27 Basic airway management Anterior traction of tongue:- tongue is pulled out & is held in position by tongue suture or towel clip Restoration of position of soft palate:- by disimpaction of maxilla. Oropharyngeal toilet and Suction:- all blood clot, saliva, thick mucous, foreign bodies should be cleared by digital exploration or by using cotton swabs or suction

28. Managing the airway 7/21/2024 OMFS 28 Manual resuscitator: AKA Ambu bag, bag-valve-mask (BMV) Portable, hand-held device that allows for the delivery of positive pressure and supplemental oxygen to the airway Generic parts: Self-inflating bag Air intake valve Nonrebreathing valve Exhalation valve Oxygen reservoir

29. Managing the airway 7/21/2024 OMFS 29 Uses Ventilation during a resuscitation effort Transport of a ventilator-dependent patient Hyperinflation and delivery of enriched oxygen mixtures before and after a suctioning procedure To generate airway pressures and large tidal volume to expand atelectatic lung segments Adjunct in directed coughing

30. Advanced airway management 7/21/2024 OMFS 30 Extraglottic or Supraglottic devices Ensure patency of the upper respiratory tract without entry into the trachea by bridging the oral and pharyngeal spaces Oropharyngeal airways Nasopharyngeal airways, Supraglottic devices

31. Advanced airway management 7/21/2024 OMFS 31 Oropharyngeal Airways Oral airways are inserted into the mouth behind the tongue Function Restores airway patency by separating the tongue from the posterior wall of the pharynx Insertion orally Use jaw lift or tongue displacement Correct sizing Measure from the corner of the patient’s mouth to angle of the jaw Incorrect placement can worsen obstruction! Used in comatose patients

32. Advanced airway management 7/21/2024 OMFS 32 Insertion Using a head-tilt-chin-lift, a modified jaw-thrust, or by grasping the tongue and jaw by placing your thumb in the patient's mouth, move the tongue forward. Position the OPA with the tip in the patient's mouth and slowly insert the OPA At the point when slight resistance is met, insertion should continue while simultaneously rotating the OPA 180°. Advance the OPA until the flange is resting on or just above the patient's teeth.

33. Advanced airway management 7/21/2024 OMFS 33 Nasopharyngeal Airways Function Restores airway patency by separating the tongue from the posterior wall of the pharynx Used when oral placement is not possible Insertion Nasally Necessary to check placement Correct sizing Measure from the patient’s earlobe to the tip of the nose Used in awake patients

34. Advanced airway management 7/21/2024 OMFS 34 Insertion First check the nostril for signs of fracture or obstruction then apply generous amounts of a water-based lubricant to the NPA taking care not to fill the tip with the lubricant Orient the bevel end so that it will pass along the inside of the nasal cavity with minimal effort Insert the NPA until the flange (the large end of the tube) is seated on the patient's nose

35. Advanced airway management 7/21/2024 OMFS 35 Supraglottic Airway Devices (SAD) Have a role in managing patients who require an advanced airway adjunct, but in whom intubation has failed or is unlikely to succeed. Include Laryngeal mask airway, intubating laryngeal mask airway, Laryngeal tube airway, intubating laryngeal tube airway, Multilumen esophageal airway

36. Advanced airway management 7/21/2024 OMFS 36 Laryngeal Mask Airway (LMA) Designed to form a low-pressure seal in the laryngeal inlet by means of an inflated cuff Maintains a patent upper airway and facilitates ventilation Designed to be inserter blindly Used for difficult intubation and Short-term Insertion This tube, when inserted into the larynx and the laryngeal cuff inflated, provides a closed seal system to ventilate the lower airway and protect against aspiration.

37. Advanced airway management 7/21/2024 OMFS 37 Multilumen Esophageal Airway To provide oxygenation and ventilation when a definitive airway is not feasible. One of the ports occludes the esophagus and the other provides air to the trachea. Using a CO2 detector provides evidence of airway ventilation. The multilumen esophageal airway device must be removed and/or a definitive airway provided after appropriate assessment.

38. Advanced airway management 7/21/2024 OMFS 38 Requires a tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to oxygen-enriched assisted ventilation, and the airway secured in place with an appropriate stabilizing method Types of definitive airways Tracheal intubation (orotracheal tube, nasotracheal tube) Surgical methods (cricothyroidotomy, and tracheotomy)

39. NEED FORAIRWAY PROTECTION NEED FOR VENTILATION OR OXYGENATION Severe maxillofacial fractures • Risk for aspiration from bleeding and/or vomiting Neck injury • Neck hematoma • Laryngeal or tracheal injury • Inhalation injury from burns and facial burns • Stridor• Voice change Head injury • Unconscious • Combative Inadequate respiratory efforts • Tachypnea • Hypoxia • Hypercarbia • Cyanosis • Combativeness • Progressive change • Accessory muscle use • Respiratory muscle paralysis • Abdominal breathing Acute neurological deterioration or herniation Apnea from loss of consciousness or neuromuscular paralysis Indications for definitive airway management 7/21/2024 OMFS 39

40. Advanced airway management 7/21/2024 OMFS 40 Endotracheal intubation Is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. Can be oral and nasal routes of intubation depends upon the surgical requirements, the presence of associated nasal and base of skull injuries. First establish the presence or absence of a c-spine fracture

41. Advanced airway management 7/21/2024 OMFS 41 Function Relieve airway obstruction Facilitate secretion removal Protect against aspiration Provide positive pressure ventilation Insertion Site Nasally Orally Placement In the trachea 3 – 5 cm above the carina

42. Advanced airway management 7/21/2024 OMFS 42 Endotracheal intubation technique Step 1: Assemble and Check Equipment Step 2: Position the patient Step 3: Preoxygenate the Patient with Resuscitator / Mask Step 4: Insert the Laryngoscope Step 5: Visualize the Glottis Step 6: Displace the Epiglottis Step 7: Insert the Tube Step 8: Assess Tube Position (3 - 5 cm above carina) Step 9: Secure the Endotracheal Tube

43. Advanced airway management 7/21/2024 OMFS 43 Hazards of Endotracheal Intubation Post- extubation mucosal edema Trauma Aspiration Bleeding Infection Tube problems (pilot balloon, kinking etc.)

44. Assessing patient for difficult airway 7/21/2024 OMFS 44 Difficulty Endotracheal Intubation Difficult Bag-Mask-Valve (BMV) L   Look externally E   Evaluate 3-3-2 M  Mallapati* O  Obstruction/Obesity N  Neck Mobility** B Beard O Obstructed/Obese/OSA N Neck Stiffness / Neck Mass E Expecting (Pregnant) S Stridor / Snores (OSA)** Difficult Laryngeal Mask Airway (LMA) Difficult Cricothyrotomy R  Restricted Mouth Opening O  Obstruction D  Distorted airway anatomy S  Stiff Lungs / Neck S  Surgery H  Hematoma, Have Infection (Abscess) O  Obesity R  Radiation T  Trauma, Tumor Airway mnemonics modified from the STARS TM  Manual & Walls et al. (4 th  edition)

45. Surgical airway 7/21/2024 OMFS 45 Needle cricothyroidotomy: 12-14G Angiocath + syringe Hyperextend neck Palpate cricothyroid membrane Apply Betadyne, Lidocaine Advance needle at 45 angle until air is aspirated Advance catheter, remove needle, attach hub to 3-mm ET adapter and oxygen Only useful for 45min due to poor CO2 exchange!

46. Surgical airway 7/21/2024 OMFS 46 Surgical Cricothyroidotomy Hyperextend neck Palpate cricothyroid membrane Apply Betadyne, Lidocaine 3-4cm midline vertical incision through cervical fascia and strap muscles Incise cricothyroid membrane horizontally; use hemostat to hold open Insert 5-7mm tracheostomy tube (or ET tube), attach to oxygen supply Convert to formal tracheostomy in 24h!

47. Surgical airway 7/21/2024 OMFS 47 Tracheostomy: is a surgical airway procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe) Rarely for emergencies Usually for ventilator weaning Many techniques (percutaneous, surgical)

48. Surgical airway 7/21/2024 OMFS 48 Indications for tracheostomy In extensive maxillofacial injuries Lack of tongue control Gross retro position of middle third of face Potential edema pharynx Uncontrolled oral/nasopharyngeal bleeding Concomitant laryngeal or tracheal injury

49. Submental Orotracheal Intubation for Maxillofacial Surgery 7/21/2024 OMFS 49 Requires the use of a spiral reinforced armored endotracheal tube. Indication In patients with comminuted fracture of the midface or the nose, where nasal intubation is contraindicated, In patients who require restoration of the occlusion, and In patients whose condition permits extubation at the end of surgery. Contraindication In patients with comminuted mandibular fractures.

50. Submental Orotracheal Intubation for Maxillofacial Surgery 7/21/2024 OMFS 50 Surgical Technique An orotracheal intubation, a 2 cm incision half way between the chin and the angel of the mandible, a blunt dissection through superficial fascia, platysma, and mylohyoid to the oral floor. Create a tunnel for passing the tube with forceps Pass the tube through the tunnel, using gentle rotational movements. Connect the tube to the ventilating machine and sutures are used to fix the tube's position

51. Submental Orotracheal Intubation for Maxillofacial Surgery 7/21/2024 OMFS 51 Complications Bleeding Damage to the lingual nerve, and The marginal mandibular branch of the facial nerve, Damage to the duct of the submandibular gland, Damage to the sublingual gland, Salivary fistulae, and skin infections

52. A decision-making algorithm for securing the airway of a patient with maxillofacial trauma 7/21/2024 OMFS 52

53. B- Breathing and Ventilation 7/21/2024 OMFS 53 Requires adequate function of the lungs, chest wall, and diaphragm Can be compromised by Airway obstruction, Altered ventilatory mechanics, Central nervous system (CNS) depression Clinicians must rapidly examine and evaluate each component

54. B- Breathing and Ventilation 7/21/2024 OMFS 54 Identifying objective signs of inadequate ventilation General Inspection Tracheal Deviation Accessory muscle use and Retractions Paradoxical chest wall movement Auscultation to assess for gas exchange bilaterally Palpation for broken ribs and injuries to chest wall Identify Life Threatening Injuries Massive hemopneumothorax Flail chest and Rib fractures Pulmonary contusion Tension Pneumothorax

55. B- Breathing and Ventilation 7/21/2024 OMFS 55 Pneumothorax Air trapping in the pleural space between the lung and chest wall Sufficient pressure builds up and pressure to compress the lungs and shift the mediastinum Physical exam Absent breath sounds and Air hunger Distended neck veins and Tracheal shift Treatment Needle Decompression 2nd Intercostals space, Midclavicular line Tube Thoracostomy 5th Intercostals space, Anterior axillary line

56. B- Breathing and Ventilation 7/21/2024 OMFS 56 Hemothorax Blood collecting in the pleural space and is common after penetrating and blunt chest trauma Source of bleeding:- Lung, chest wall, heart, great vessels and diaphragm Physical Exam Absent or diminished breath sounds Dullness to percussion over chest Hemodynamic instability Treatment Large Caliber Tube Thoracostomy 10-20% of cases will require Thoracostomy for control of bleeding

57. B- Breathing and Ventilation 7/21/2024 OMFS 57 Flail Chest Direct injury to the chest resulting in an unstable segment of the chest wall that moves separately from remainder of thoracic cage Physical exam Paradoxical movement of chest segment Treatment Early intubation for patients with respiratory distress Avoidance of overaggressive fluid resuscitation TUBE THORACOSTOMY Insertion site – 5th intercostal space, – Anterior axillary line.

58. C- Circulation with hemorrhage control 7/21/2024 OMFS 58 In patients with facial trauma, life- threatening bleeding occurs in 1% to 11% The hemorrhage affects the patient's condition and prognosis in several ways: Blood in the oral cavity often excludes mask ventilation, Preclude good view of airway anatomy, making intubation very difficult, Significant hemorrhage may cause circulatory compromise that may be fatal, Coagulation may deteriorate due to massive blood transfusion, The surgical field conditions during bleeding are less than optimal for operating.

59. C- Circulation with hemorrhage control 7/21/2024 OMFS 59 Management of the patient with facial bleeding includes Local control of the bleeding Initial digital compression and packing Surgical techniques Appropriate dissection Vascular clamps, forceps and Diathermy Intraluminal balloons Arterial ligation and embolization Minimal access surgery Soft tissue wounds suturing

60. C- Circulation with hemorrhage control 7/21/2024 OMFS 60 Volume replacement If the patient is in shock, iv fluids are started to restore the blood volume After cross matching blood transfusion is started Adjuvant measures like; Relieving the pain Making the patient comfortable Gentle handling and compression dressings and Splinting of fractures can be done simultaneously

61. C- Circulation with hemorrhage control 7/21/2024 OMFS 61

62. C- Circulation with hemorrhage control 7/21/2024 OMFS 62 Observation & monitoring Close observation of a patient should be done Pulse, RR, BP should be monitored. Control infection by antibiotics & anti-inflammatory analgesics TT is given Adequate nutrition is given.

63. C- Circulation with hemorrhage control 7/21/2024 OMFS 63 Acc to Perry et al, Damage control has four phases. Anticipation of ‘at- risk’ patients, based on the mechanism of injury, and initial vital signs. Damage-control procedures and surgery. These focus only on controlling bleeding and preventing infection. A period on ICU where the patient is fully resuscitated, minimizing the biologic second hit. A planned second procedure, where definitive repair of all injuries is carried out.

64. D- Dysfunction and neurological Examination 7/21/2024 OMFS 64 Acc to Haug et al. 17.5% patients with facial fractures had some form of closed head injury whereas almost 10% sustained a severe intracranial injury Conditions that may alter level of consciousness should be excluded Hypoglycemia Alcohol and drug abuse For a very rapid assessment of the patient’s Mental status GCS, Pupillary size and reaction, cranial nerve and motor function

65. Neurological Examination 7/21/2024 OMFS 65 Glasgow Coma Score is used to objectively describe the extent of impaired consciousness level according to three aspects of responsiveness: Severity of head injury is classified according to GCS Minor head injury: 15 with no LOC Mild head injury: 14 or 15 with LOC Moderate head injury: 9-13 Severe head injury: 3 - 8

66. D- Dysfunction and neurological Examination 7/21/2024 OMFS 66 Pupil size and Reaction Examine Shape, size, symmetry of pupil and reaction to light Normal pupils Round and equal in size Average size is 2 to 5 mm in diameter. Reaction to light Direct light reflex Consensual light reflex

67. D- Dysfunction and neurological Examination 7/21/2024 OMFS 67 Cranial Nerve Examination Olfactory nerve Most common nerve injured during head trauma Each nostril, distinct smell Optic nerve Visual acuity, Visual fields, Color vision Fundoscopy Pupillary response

68. D- Dysfunction and neurological Examination 7/21/2024 OMFS 68 Oculomotor, Trochlear and Abducent Nerves Responsible for EOM Superior oblique = Trochlear Lateral rectus = Abducent Patient follows object through cardinal positions of gaze Trigeminal nerve Sensation to the face Motor to muscles of mastication Corneal reflex (sensory)

69. D- Dysfunction and neurological Examination 7/21/2024 OMFS 69 Facial Nerve Muscles of facial expression Sensation to EAM Taste to anterior 2/3 of tongue Lacrimal gland Test muscles of facial expression and taste Vestibulocochlear nerve Auditory and vestibular components Rinne’s test and Weber’s test Bedside crude hearing test

70. D- Dysfunction and neurological Examination 7/21/2024 OMFS 70 Glossopharyngeal Nerve and Vagus Nerve Gag reflex and ask patient say “ah” Accessory Nerve Motor to SCM and trapezius Shoulder shrug and head turn against resistance Hypoglossal Nerve Motor to muscles of tongue Stick out tongue

71. D- Dysfunction and neurological Examination 7/21/2024 OMFS 71 Motor Examination Bulk Compare sides UMN lesion – maintain bulk LMN lesion – decreased bulk Fasciculation Tone Compare sides UMN lesion – increased tone LMN lesion – decreased tone Power Medical Research Council Grading 0 = no movement 1 = flicker 2 = moves without gravity 3 = moves against gravity 4 = weakness against resistance 4+ = minimal weakness against resistance 5 = normal power

72. E- Exposure and Hypothermia prevention 7/21/2024 OMFS 72 EXPOSURE Completely undress patient and assess for other injuries Injuries cannot be diagnosed until seen by provider Logroll the patient to examine patient’s back Maintain cervical spinal immobilization Palpate along thoracic and lumbar spine Avoid hypothermia Apply warm blankets after removing clothes Hypothermia lead to Coagulopathy Increases risk of hemorrhage

73. Adjuncts to the primary survey 7/21/2024 OMFS 73 Vital Signs/ECG monitoring ABGs POX/CO2 CBC, BG and RH Blood sugar Coagulation studies Urinary output CXR, C-spine, Pelvis, DPL ,Ultrasound

74. Adjuncts to the primary survey 7/21/2024 OMFS 74 Imaging studies For # of middle 1/3 of face CT Scan PA view skull Water`s view Lateral view skull Submentovertex view

75. Adjuncts to the primary survey 7/21/2024 OMFS 75 Imaging studies For # of mandible OPG Right & left lateral oblique view of mandible Reverse towns view PA view mandible Occlusal view IOPA

76. Secondary survey and Definitive management 7/21/2024 OMFS 76 The purpose of the secondary survey; To Review the patient’s history To identify all injuries through a more thorough ‘head to toe’ examination It allows confirmation or correction of preoperative dx. Secondary survey includes AMPLE History Allergies Medications Past Medical History, Pregnancy Last Meal Events surrounding injury, Environment

77. Secondary survey and Definitive management 7/21/2024 OMFS 77 Physical Exam Head Inspection of the face for asymmetry. Inspect head and face for laceration, abrasion, contusion Palpate the entire face. Supraorbital and Infraorbital rim Zygomatic arches Mandible

78. Secondary survey and Definitive management 7/21/2024 OMFS 78 Eye Check visual acuity. Check pupils for roundness and reactivity. Test extra ocular muscles. Examine the eyelids for lacerations. Examine the cornea for abrasions and lacerations. Perform fundoscopic exam and examine the posterior chamber and the retina. Ear Inspect for bleeding and CSF leak Check for hearing impairment Examine the ear for lacerations.

79. Secondary survey and Definitive management 7/21/2024 OMFS 79 Nose Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge. Inspect nasal septum for septal hematoma, CSF or blood. Palpate nose for crepitus, deformity and subcutaneous air. Mouth Inspect the teeth for malocclusions, bleeding and step-off. Manipulation of each tooth. Check for lacerations. Neck Inspect for respiratory distress and gross bleeding or presence of a hematoma Palpate for subcutaneous emphysema

80. Secondary survey and Definitive management 7/21/2024 OMFS 80 Complete anatomic evaluation Chest Abdomen Pelvis Genitourinary Extremities Neurological

81. Secondary survey and Definitive management 7/21/2024 OMFS 81 Definitive Care Comprehensive Treatment of all Injuries Fracture Stabilization Necessary Operative Intervention Appropriate Intensive Care Rehabilitation Stabilization & Appropriate Transfer In facial trauma, is to deliver appropriate treatments for Soft tissue injuries Fracture of facial Skelton Injuries to special regions (eye, nerve, vessels, salivary gland and dentition)

82. Management of Soft tissue injuries 7/21/2024 OMFS 82 Principle of management of soft tissue injuries include Control of bleeding, Copious irrigation of the wound, Antibiotics prophylaxis to Trauma Patients Tetanus prophylaxis Debridement of devitalized tissue, and Removal of foreign bodies before closure.

83. Management of Maxillofacial fractures 7/21/2024 OMFS 83 Principles of maxillofacial fracture repair Reduction Closed Reduction Open Reduction Fixation Indirect fixation Direct fixation Immobilization Early return to function

84. Reduction 7/21/2024 OMFS 84 It is the restoration of fractured fragments to their original position. Closed reduction No surgical intervention is needed for closed reduction Occlusion of teeth is used as the guiding factor It can be carried out with Manipulation or Traction Reduction by Manipulation When the fragments are mobile without much overriding or impaction & patient immediately comes after trauma. Digital manipulation or disimpaction forceps can be used for reduction

85. Reduction 7/21/2024 OMFS 85 Reduction by traction The fractured fragments are subjected to gradual elastic traction by placing elastics from upper to lower prefabricated arch bars. Surgical reduction Allows visual identification of fractured fragments. Indications Displaced # Multiple # Associated condylar #

86. Fixation 7/21/2024 OMFS 86 Surgical procedure used to internally set and stabilize fractured bones until biologic healing completed Fractured fragments are fixed to prevent displacement

87. Direct fixation/Bone plate osteosynthesis 7/21/2024 OMFS 87 Indications If IMF is contraindicated Edentulous patients with loss of bone segments. If early mobilization of joint is required as in condylar # Contraindications Heavily contaminated # with active infection & discharge Badly comminuted # In mixed dentition period Presence of gross pathologies in bone

88. Immobilization 7/21/2024 OMFS 88 The fixation devices is retained to stabilize the reduced fragments until a bony union takes place Duration For maxillary # 3 to 4 weeks immobilization is enough For mandible # 4 to 6 weeks immobilization In condylar # 2 to 3 weeks immobilization to prevent ankylosis Technique Dental wiring Arch bar CAP Splint Bonded modified orthodontic brackets Circumferential wiring

89. Take home message 7/21/2024 OMFS 89 Use of efficient, systematic, and standardized scales to assess a trauma patient can reduce trauma mortality. Clinicians can quickly assess A, B, C, and D in a trauma patient (10-second assessment) by identifying themselves, asking the patient for his or her name, and asking what happened Secondary assessment includes an abbreviated patient history and objective evaluation of systems: head and skull, maxillofacial area and neck, chest, spinal cord, abdomen, genitourinary, and extremities

90. References 7/21/2024 OMFS 90 Petersons Principles of Oral & Maxillofacial Surgery 4 th edition ORAL AND MAXILLOFACIAL TRAUMA, Raymond_J_Fonseca, 4 th edition ATLS, Advanced Trauma Life Support, student course manual, 10 th edition UpToDate Michal Barak, Hany Bahouth , Yoav Leiser , Imad Abu El- Naaj , "Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach", BioMed Research International, vol. 2015, Article ID 724032, 9 pages, 2015. https://doi.org/10.1155/2015/724032

91. Thank you! 7/21/2024 OMFS 91