Ocular and faciomaxillary trauma - reviewed.ppt

Ocular and faciomaxillary trauma - reviewed.ppt

1. OCULAR AND
FACIOMAXILLARY
TRAUMA

2. OBJECTIVES
REVIEW OCULAR AND FACIAL ANATOMY
DEFINE THE TYPES OF OCULAR AND
FACIAL TRAUMA
EXPLAIN THE COMMON CONDITIONS
FOLLOWING OCULAR AND FACIAL
TRAUMA
EXPLAIN THE ASSESSMENT, MANAGEMENT,
AND COMPLICATIONS OF OCULAR AND
FACIAL TRAUMA
REVIEW THE NURSING RESPONSIBILITIES IN
OCULAR AND FACIAL TRAUMA
2

3. DEFINITION
Facial injury
Any injury to the face that may induce airway obstruction, deformity, bone, and
soft tissue damage.
(Danis et al, 2007)
Ocular trauma
Any injury to the eye
Started from soft tissue to bone fracture including nerves and
vessels
3

4. INTRODUCTION
Hwang, 2020
Facial injuries account for 3% to 29% of sports injuries, and sports
injuries account for 11.3% to 42.1% of facial fractures. Fractures of
the nasal bone were the most common in all sports (40% – 60.5%)
Mandibular fractures were common in martial arts (33.3%) soccer
(11%)
Orbital bone fractures were common in basketball (20.0%), ice
sports (18.2%), and baseball (15.8%)
Fractures of the zygoma occurred frequently in martial arts (13.3%)
and soccer (10%).4

5. ANATOMY
5

6. WHY FACE ?!
Compromise the airway.
Is the beginning of both the Respiratory and GI tract.
Sits directly in front of cranial structures, thus, mostly associated
with brain and spinal injuries.
Has some of the five senses; taste, smell, and sight ,,,, plays a
general role in speech.
It is important for a person’s identity.
6

7. CAUSES
7
MO T O R
V E H I
CLE
A C C I D
EN T
S PO RT
I N J U RI
ES
E X P L O S I O
N S
FALLS ASSAULT

8. TYPES OF FACIAL TRAUMA
8
Facial laceration.
Contusion.
Dislocation
(mandibular).
Bone fracture:
Orbital fracture.
Nasal fracture.
Zygomatic fracture.
Mandibular fracture.
Maxilla (Le Fort fractures).

9. FACIALLACERATION
ASSESSMENT
Primary survey
Secondary survey
MANAGEMENT
Control bleeding
Cleaning
Dressing
Suturing
Antibiotics
Grafting (if required)
9

10. FACIALCONTUSION
ASSESSMENT
Primary survey
Secondary survey
Assess for the extent of contusion as other
tissues might be involved e.g. muscles,
bones, eyes
MANAGEMENT
Ice pack application
Keep head raised
Manage accordingly if other
tissues involved
10

11. DISLOCATION (MANDIBLE)
ASSESSMENT
Primary survey
Secondary survey
Causes:
Excessive yawning, Chewing &
laughing. Symptoms:
Open/ unable to Close mouth.
MANAGEMENT
Manual closed reduction by dentist
under analgesia & short-acting muscle
relaxant.
11

12. MANDIBULAR FRACTURE
ASSESSMENT
Primary survey
Secondary survey
Symptoms:
Airway compromise.
Soft tissue swelling & ecchymosis.
Loose teeth or malalignment.
Severe jaw pain & tenderness.
MANAGEMENT
Surgical intervention involving the Dentist.
12

13. LEFORTFRACTURE
13
CAUSES
Motor vehicle
accidents
Assault
Falls
MAN
AGEMENT
Ensure airway patency and
management
Pain control
Cold compression
Keep head elevated
Prepare for surgical intervention
Type ITransverse fracture through
the maxillary sinuses, lower
nasal septum, and
pterygoid plates
Type IIOblique fracture crossing
zygomaticomaxillary suture,
inferior orbital rim, nasal
bridge
Type IIIFracture above the
zygomatic arch, through the
lateral and medial orbital
walls and nasofrontal
suture

14. LE FORT I
( LOW-LEVEL FRACTURE)
Transverse or horizontal fracture across the lower
maxilla.
Separating the maxilla from the hard palate (floating).
It may involve the alveolar ridge along with teeth
fracture.
Minimal deformity with bilateral epistaxis.
14

15. LE FORT II
Pyramidal-shaped fracture passes through the
lateral orbital rim, zygomatic arches, and roof of the
nose.
Compromising the airway & producing an open
bite.
Bilateral subcutaneous hematoma.
facial edema, epistaxis, subconjunctival hemorrhage,
CSF rhinorrhea, mobile maxilla, and telecanthus.
Malocclusion, lip swelling or contusion.
Infra-orbital nerve damage.
15

16. LE FORT III
( CRÂNIOFACIAL DISJONCTION)
It results in complete separation of the facial skeleton from
the cranial skeleton/ potential airway obstruction/ LOC.
Flattened, enlarged face with significant bleeding.
Massive facial edema & ecchymosis.
Deformity & asymmetry.
LOC with rhinorrhea CSF.
Visual changes; Diplopia/ pupils changes.
Cheek
paresthesia.
16

17. ZYGOMATIC FRACTURE
ASSESSMENT
Primary survey
Secondary survey
Symptoms:
Subconjunctival hemorrhage &
periorbital ecchymosis.
Facial edema & deformity/ ptosis.
Disturbed ocular movement &
visual acuity.
CSF leakage sometimes.
Depressed cheek.
MANAGEMENT
Medical management
Closed reduction
Open reduction with internal
fixation (ORIF)
17

18. NASALBONEFRACTURE
ASSESSMENT
Primary survey
Secondary
survey Causes:
RTA
Sports
Assa
ult
Symptoms:
Nasal
defor
mity
Epistax
is
Edema and ecchymosis of the nose
and periorbital area
Crepitus
MANAGEMENT
Medical management
Closed reduction
Open reduction with internal
fixation (ORIF)
18

19. EXAMPLESOFNASALFRACTURE
19

20. ORBITALFRACTURE
ORBITALRIMFRACTURE
ASSESSMENT
Primary survey
Secondary
survey Causes:
Blunt force trauma
Symptoms:
Cheek
paresthesia
Swelling
Ecchymosis
MANAGEMENT
Medical management
Closed reduction
Open reduction with internal
fixation (ORIF)
20

21. COMPLICATIONS OFMAXILLOFACIAL TRAUMA
21
Airway compromise.
Aspiration.
Infection.
Scar & facial deformity.
Loss of facial function & sensation (nerve
damage).
Chronic sinusitis.
Malnutrition & weight loss.
Depression.

22. OCULAR TRAUMA
22

23. ANATOMY

24. ANATOMY
24

25. TYPES OF OCULAR TRAUMA
M ECHA NI CAL PHYSI CA L CHEM I CA L THER M A
L
B L U N T
P E N E TR AT I
NG P E R F O R A
TI NG
U V R
I N F R A R E D
A C I D S
A L K A L I N E
H E A T
C O L D
25

26. EYE LID
PR EOCULAR H EMATOMA:
M O S T C O M M O N E Y E L I D B L U N T I N J
U R Y
Hematoma
Focal collection of blood
Ecchymosis
Diffuse bruising or edema
Both are innocuous if other serious injuries are
excluded
26

27. TREATMENT
27
C O L D C O M P R ES S I
ON
I N T H E F I R S T 2 4 H O U
R S
M E D I C AT I ON S
A N T I E D EMA
( A N T I - I N F L AM MA TO
RY )
D R U G S
E . G . A L P H A
C H Y M O T R Y P SI N
W A R M C O M P RE S S
I ON
A F T E R 2 4 H O U R S

28. L I DL A C E R A T I
O N :
28
H O R I Z O N T
AL L A C E R A
T I ON
V E R T I C A L
L A C E R A T I
ON
+
L I D M A R G I N
L A C E R A T I O N
C A N A L I C U L A
R L A C E R A T I
O N

29. ORBITALFRACTURE:
FLO O R A N D ME D I A L WA
LL FRA C T U RE
( BLO WO UT FRA C T U RE )
Cause:
A sudden increase in orbital pressure from
impacting objects greater than orbit
diameter.
Symptoms:
Lid edema, laceration, conjunctiva
chemosis
Subcutaneous emphysema
Enophthalmos
Diplopia
Limitation in eye movement
Palpable orbital margin
Tear drop sign in CT
TREATMENT
Conservative
•Antibiotics
•Ice Compression
•Nasal decongestant
•Not to blow the nose
•Steroids if optic nerve compression suspected
Surgical
Within two weeks of trauma if:
•Enophthalmos > 2 cm
•Persistent diplopia
•Fracture > ½ of orbit floor
29

30. ORBITALFLOORANDMEDIALWALLFRACTURE
( BL OWOU TF RACTU RE)
30

31. ORBITALROOFANDLATERAL WALLFRACTURE
Associated with other craniofacial fractures
Might be accompanied by pulsating proptosis
CSF
31

32. ORBITALHAEMORRHAGE
CAUSES:
Trauma
Iatrogenic (retrobulbar anesthesia)
Spontaneous (bleeding disorders)
Symptoms:
Lid edema, conjunctiva chemosis, hematoma
Proptosis
Limitation in ocular motility
Increase IOP
Fundus swelling
T REATMENT
Compression
Medications (mannitol & acetazolamide)
32

33. GLOBE RUPTURE
CAUSES
Trauma to the eyeball
Symptoms:
Eye pain
Vision loss.
Fluid leaking from the eye.
Extrusion of ocular tissue from the
eyeball (eye tissue is pushed out).
•Globe rupture is a medical emergency
T REATMENT
Surgical intervention
Medications (analgesia, antibiotics, artificial tears)
Don’t rub or touch the eye.
Avoid any pressure on the eye at any time.
Keep the eye protected.
Avoid anything that may cause you to strain
(lifting, coughing, sneezing, toilet strain, etc.).
Stay in bed with head elevated about 30 degrees.
33

34. CONJUNCTIVAL FB
34

35. SU BCON JU N CTI VALHEMORRHAG
E
CAUSES:
Trauma
Uncontrolled HTN
Valsalva
Bleeding disorders
Sneezing/coughing
Straining
Spontaneous
•Resolves spontaneously
35

36. CORNEAL ABRASION
CORNEAL ABRASION
Breach of corneal epithelium
Cause:
Trauma
Test :
Fluorescein test (stained)
Treatment:
Topical ( antibiotics,
lubricants, cycloplegics)
36

37. CORNEAL FB
37

38. HYPHEMA
38
H YPH EMA
Hemorrhage inside the anterior chamber
leads to blood collection between the
cornea and the iris.
Cause:
Trauma (sport injuries)
Symptoms:
Sensitivity to lights
pain in the eye
blurry, clouded, or
blocked vision
Blood level is
obvious in the eye
TR EATMENT:
Bed rest in a sitting or semi-
upright position
Avoid NSAIDs
Medical treatment
Reduce IOP
Topical steroids to reduce
inflammation
Surgical with specific indications

39. HYPHEMA
39

40. OCULAR CHEMICAL INJURIES
ACID
Less severe than alkali injuries (Acids have lower
than normal pH values of the human eye (7.4)
they precipitate tissue protein, creating a barrier
to further ocular penetration)
Copious irrigation with an isotonic solution to
neutralize PH.
Assessment
Eye fornices, visual acuity, IOP, perilimbal
blanching.
Treatment:
Topical antibiotic, cycloplegic, and antiglaucoma
therapy
ALKALINE
Cause severe corneal damage by pH change,
ulceration, proteolyzes, and collagen synthesis
defects.
Alkali substances are lipophilic and penetrate
the eye more rapidly than acids.
Copious irrigation with an isotonic solution
to neutralize PH.
Assessment
Eye fornices, visual acuity, IOP, perilimbal
blanching.
Treatment:
Topical antibiotic, cycloplegic, and
antiglaucoma therapy
4 0

41. OCULAR CHEMICAL INJURIES
41

42. OCULAR PHYSICALINJURIES
UVR
Radiation of wavelengths shorter than 300 nm
Actinic rays can damage the corneal
epithelium especially if reflected from bright
surfaces such as snow, water, and sand.
Since 80% of these rays are absorbed by
the lens, they can cause cataractous
changes.
e.g. welding exposure harm without distance
limit
Symptoms: (appears 6-10 hrs. after exposure)
Irritation, photophobia, FB sensation, pain,
lid spasm
Treatment:
Analgesia, cycloplegics, monitoring for 24
hrs.
INFRARED
Wave lengths greater than 750 nm
Can cause cataract changes, especially in less
than 3 feet distance long-term exposure
(glassblower's cataract)
e.g. welding exposure harm is reduced if
distance increase
Symptoms: (appears 6-10 hrs. after exposure)
Irritation, photophobia, FB sensation, pain,
lid spasm
Treatment:
Analgesia, cycloplegics, monitoring for 24
hrs.
42

43. OCULAR THERMAL TRAUMA
C AU S ES :
Direct contact, splash (most
common) Assessment:
Pupillary reaction and size
Visual acuity
Extraocular movement
IOP
Fluorescein test
Treatment:
Copious irrigation
Search for FB
Specialty consultation43

44. COMPLICATIONS OFOCULARTRAUMA
Vision loss
Depression
Scars
Identity effects
Socioeconomical complications:
•Loss of job
•withdrawal
Post traumatic complications:
•Traumatic cataract
•Traumatic glaucoma
•Retinal detachment
•Corneal scaring/obesity
•Optic nerve avulsion
44

45. NURSING RESPONSIBILITIES IN
OCULAR AND
MAXILLOFACIAL INJURIES
Frequent assessment for airway patency.
Frequent neurological assessment especially facial nerve function.
Maintain Fowler’s position as much as possible.
Assess for CSF or active bleeding.
Immobilize the patient with a wrap surrounding the head (mandibular).
Provide liquid to a very soft diet (mandibular).
Educate the patient about the importance of wound care and stitch removal to reduce the risk of infection
and possible wound marks.
Assess for visual changes.
Do not shave an eyebrow.
Provide psychological support.
45

46. REFERENCES
1.Advanced Trauma Life Support, student course manual (2018). UAS: Author
2.Al-Hassani. A, Ahmad. K, El-Menyar. A, Abutaka. A, Mekkodathil. A, Peralta. R,,, Al-Thani. H. (2019). Prevalence and patterns of maxillofacial
trauma: a retrospective descriptive study. European Journal of Trauma and Emergency Surgery. doi.org/10.1007/s00068-019-01174-6
3.Danis D, Blansfield J, Geravsini A (2007) Hand Book of Clinical Trauma Care The First Hour, US, Mosby Elsevier.
4.Dolan B & Holt L. 2013. Accident & Emergency; Theory into Practice. 2nd edn. London: Ballier Tindall Elsevier.
5.Hsieh. T, Dedhia. R. D, Chiao. W, Dresner. H, Barta. R. J, Lyford-Pike. S,,, Hilger . P. A.(2020). A Guide to facial trauma triage and precautions in
the COVID-19 pandemic. American Academy of Facial Plastic and Reconstructive Surgery. Vol 22 (3). http://doi.org/10.1089/fpsam.2020.0185
6.Hwang. K. (2020). Field management of facial injuries in sports. The Journal of Craniofacial Surgery. Vol 31 (2).
doi: 10.1097/SCS.0000000000006132
7.Lee. D. W, Hong. S. W, Kim. J. H. (2019). Unilateral blindness due to retrobulbar hematoma after lower
blepharoplasty. Archives of Aesthetic Plastic
Surgery. Doi.org/10.14730/aaps.2019.01725
8.Nayduch D (2009) Nurse to Nurse Trauma Care Expert Interventions, Mc Graw Hill, USA.
9.Vaca E, Bellamy J, Sinno S & Rodriguez E. 2018. Management of High-energy Avulsive Ballistic Facial Injury: A Review of Literature
and Algorithmic Approach. Available at: www.PRSGlobalOpen.com. Accessed on 22/04/2019.
10.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779420/
11.Occupational & Environmental Medicine, Joseph Ladoue & al, last edition.
12.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7105268/
13.https://www.ncbi.nlm.nih.gov/books/NBK470379/#article-21506.s11
46

47. ANY
QUESTIONS?

48. BADER AL
SHUKAILI