Primary assessment in Maxillofacial trauma seminar.pptx

primary assessment in OMFS

1. Primary assessment in Maxillofacial Trauma Under the guidance of: Dr. Irshad Ahmad Misger Head of Department Oral and Maxillofacial Surgery Presented by : Dr Rashfiya Nazir PG ist year Oral and Maxillofacial Surgery

2. CONTENTS Introduction Initial assessment Triage Primary survey BLS Refrences

3. INTRODUCTION Refers to the initial ,rapid evaluation of a patient with facial injuries to identify & immediately address any life threatening conditions,primarily focusing on securing the airway ,assessing breathing, checking for significant bleeding & evaluating neurological status , all following the “ABCDE” protocol to prioritize critical interventions. Causes : RTA, assaults,fall from height,industrial injuries,animal bites,sports injuries,burns and war injuries.

4. Initial assessment & management must be completed in an accurate & systematic manner to quickly establish the extent of any injury to vital life support systems . Nearly 25-30% of deaths caused by injury can be prevented when an organized & systematic approach is used. Death from trauma has a trimodal distribution

5. Deaths from trauma follow a trimodal distribution 1 st peak , 40% - 50% trauma deaths, immediately or within minutes of the accident, due to lacerations of the brain, brainstem, high spinal cord, heart, aorta, or other large blood vessels. 2 nd peak , 30 % trauma related death ( mins – hour), due to hypoxia and hypovolemic shock as a result of severe chest injuries with hemothorax or cardiac tamponade, abdominal trauma with ruptured spleen or liver, or orthopaedic injuries such as fractured pelvis or long bones associated with significant blood loss. - GOLDEN HOUR becoz patients may be saved with rapid assessment & management of their injuries. 3 rd peak –occurs days or weeks after the injury due to multiple organ failure, sepsis or distress

6. Platinum Minutes “Emergency Platinum Ten Minutes (EPTM)” - emphasizes self-rescue and assisted rescue within the first ten minutes after accidental injuries and emergencies occur. The goal is to reduce the mortality and the disability rates of accidental injuries and emergencies Golden Hour The term “Golden Hour” was first introduced in 1961 by R Adams Cowley “ G olden hour” - injured patient has 1 h (60 min) from the time of injury to receive defnitive care. T hese patients may be saved with rapid assessment and management of their injuries during that time.

7. Injuries divided into 3 general categories: 1.Severe , 2. Urgent, 3. Nonurgent Immediately life threatening no immediate threat to life not immediately life e.g,compromised airway,inadequate e.g,injuries to abdomen,chest , threatening .Requires breathing,hemorrhage or shock. Orofacial structures or extremities medical or surgical Rx. require surgical intervention or repair.

8. Maxillofacial trauma & esthetic facial reconstruction peter ward booth , 11 th edition INITIAL ASSESSMENT

9. Assessment of the severity of injury Use of efficient,systematic , & standardized scales to assess a trauma patient can reduce trauma mortality. Glassgow coma scale,quantifying the severity of head trauma based on motor,verbal and eye opening response. Trauma score and revised score,assess injury to vital systems. Injury severity score,developed for patients with multiple traumatic injuries.

10. Primary goal of triage is to prioritize victims according to the severity & urgency of their injuries & the availability of the required care Triage is the sorting of patients based on their need for treatment and the available resources to provide the treatment Starts at the accident scene itself 2 types - Multiple casualties - Mass casualties TRIAGE When the number of patients and the severity of their injuries do not exceed the ability of the facility to provide care. The situation in which the number of patients and the severity of their injuries exceed the capability of the facility and the staff.

11. Glasgow Coma Scale D eveloped in 1974 by Teasdale and Jennet . It was the first attempt to quantify the severity of head injury. M otor response - level of CNS function V erbal response - CNS’s ability to integrate information E ye opening - function of brainstem activity. 15 -fully awake, responsive and have no problems with thinking ability 8 or fewer - you're in a coma Peterson; 2004; Principle of oral and maxillofacial surgery; BC Decker Inc

12. The Trauma Score : D eveloped by Champion and colleagues in 1981 to quickly assess the extent of injury to vital systems F ive variables: GCS, respiratory rate, respiratory expansion, systolic blood pressure, and capillary refill. It was later modified by Champion and coworkers to become the Revised Trauma Score in 1989. The Revised Trauma Score omitted respiratory expansion and capillary refill owing to difficulty assessing these elements in the field In start triage ,a patient with a RTS score of: 12 is labelled delayed 11 is urgent 3-10 is immediate RTS below 3 are declared dead. Peterson; 2004; Principle of oral and maxillofacial surgery; BC Decker Inc

13. Injury Severity Score : The Injury Severity Score (ISS) was developed to deal with multiple traumatic injuries to multiple organ systems. Scoring is based on the severity of injury to the three most injured organ systems, inclu d ing respiratory cardiovascular systems, CNS, abdomen, extremities, and skin . Each of the three most injured organ systems is graded from 1 (minor) to 6 (fatal). RAYMOND J. FONSECA; oral & maxillofacial trauma; fourth edition; 2013; Saunders; Elsevier

14. Mechanism of Injury : The mechanism of injury is usually one of the first issues c ommunicated by EMS to the trauma team as a patient enters the trauma bay. The mechanism of injury can provide insight into other possible injuries that have not yet resulted in significant changes in vital signs or physiologic function. RAYMOND J. FONSECA; oral & maxillofacial trauma; fourth edition; 2013; Saunders; Elsevier

15. PRIMARY SURVEY A irway maintenance with cervical spine protection B reathing and ventilation C irculation with hemorrhage control D isability—neurologic status E xposure, environmental control: Undressing the patient but preventing hypothermia

16. AIRWAY MAINTENANCE WITH CERVICAL SPINE CONTROL The highest priority in the initial assessment of the trauma patient is the establishment and maintenance of a patent airway. In the trauma patient, upper airway obstruction may be due to bleeding from oral or facial structures, aspiration of foreign materials, facial fractures, airway structure trauma, or regurgitation of stomach contents. Commonly, the upper airway is obstructed by the position of the tongue, especially in the unconscious patient

17. Hutchison et al. (1) Posteroinferior displacement of a fractured maxilla parallel to the inclined plane of the base of the skull may block the nasopharyngeal airway. (2) A bilateral fracture of the anterior mandible may cause the fractured symphysis and the tongue to slide posteriorly and block the oropharynx in the supine patient. (3) Fractured or exfoliated teeth, bone fragments, vomitus, blood, and secretions as well as foreign bodies, such as dentures, debris, and shrapnel, may block the airway anywhere along the oropharynx and larynx. (4) Hemorrhage from distinct vessels in open wounds or severe nasal bleeding from complex blood supply of the nose may also contribute to airway obstruction. (5) Soft tissue swelling and edema which result from trauma of the head and neck may cause delayed airway compromise.

18. C ervical spine injury : Suspect - sustaining injuries above the clavicle or with decreased levels of consciousness Maintenance of the cervical spine in the neutral position is best achieved with the use of a backboard, bindings, and purpose-built head immobilizers. A void hyperextension or hyperflexion of the patient’s neck during attempts to establish an airway. Oral airway devices are usually preferred with patients with decreased levels of consciousness.

19. Airway Evaluation 1. Observatio n: Agitation, labored breathing, using accessory muscles - hypoxia O btundation - accumulation of carbon dioxide or hypercarbia Cyanosis, a late sign, - inadequate oxy g enation. 2. Listen for abnormal sounds : Stridor - partial obstruction of the airway. Hoarseness - functional laryngeal obstruction. 3. Palpate the trachea and determine whether it is in the midline

20. Steps to stabilise the airway High flow oxygen is given at 15 litres /min. A jaw thrust should be performed. Chin lift or head tilt should be avoided if in case C-spine injury is suspected. An oropharyngeal airway is considered if the GCS<8. A nasopharyngeal airway should be avoided. Orotracheal intubation should be attempted only if one is confident of it, otherwise a cricothyroidotomy should be performed and the anaesthetist called for. In unsuccessful orotracheal intubation or “cannot ventilate cannot intubate situation” perform surgical airwa y

21. The jaw-thrust procedure - placement of both hands along the ascending ramus of the mandible at the mandibular angle. The fingers are placed behind the inferior border of the angle, and the thumbs are placed over the teeth or chin. The mandible is then gently pulled forward with the fingers at the angle and rotated inferiorly with pressure from the thumbs . The jaw-thrust procedure is the safest method of jaw manipulation in a patient with a suspected cervical injury. The chin-lift procedure - placing the thumb over the incisal edges of the mandibular anterior teeth and wrapping the fingers tightly around the symphysis of the mandible.

22. Endotracheal Intubation

23. Surgical Airway Needle Cricothyroidotomy : Locating the cricothyroid membrane: a. By palpating the trachea just above the sternal notch and proceed upward until the prominence of the cricoid cartilage is identified b. By palpating the thyroid notch and proceeding downward until the prominence of the cricoid cartilage is identified A needle is inserted into the cricothyroid membrane. A jet system is then connected, which will provide oxygen until a more definitive airway can be established. T emporary airway - can be oxygenated for a maximum of 30 to 45 minutes.

24. Surgical Cricothyroidotomy : A surgical incision made on the skin, extending to the cricothyroid membrane. A hemostat or scalpel handle may be used to dilate the opening, followed by the insertion of a small-caliber tube into the trachea (5 to 7 mm outer diameter). This is not recommended for children because of potential damage to the cricoid cartilage

25. Technique of surgical cricothyroidotomy A, Assemble the required equipment: local anesthetic with lidocaine (lignocaine) and epinephrine (adrenaline) for both anesthesia and vasoconstriction. B, Secure in-line immobilization of the patient’s head by an assistant. Make a 3-cm horizontal incision through skin over cricothyroid membrane (having first removed the cannula if needle cricothyroidotomy was performed). C, Stab vertically down through membrane and make a 1-cm incision. D, Insert tracheal dilator horizontally and open it, separating the thyroid and cricoid cartilages. Suck out the trachea with a Yankeur -type sucker. E, Having checked that the cuff inflates, insert the tracheostomy tube into the trachea. F, Remove the introducer, inflate the cuff, and connect oxygen supply via Ambu bag. Reassess and monitor O2 saturation and end-tidal CO2; auscultate both sides of the chest for air entry.

26. BREATHING & VENTILATION Once the airway has been secured, breathing and ventilation must be assessed. THORACIC INJURIES A: Airway obstruction T: Tension pneumothorax O: Open pneumothorax M: Massive haemothorax F: Flail chest

27. Breathing and ventilation Once a patent airway is verified or established, pulmonary function should be assessed. The lungs, chest wall, and diaphragm must all function adequately to ensure proper ventilation. Inadequate ventilation may result in hypoxemia, hypercarbia, cyanosis, depressed level of consciousness, bradycardia, tachycardia, hypertension, and/or hypotension. Breathing evaluation is most readily accomplished by visual inspection and palpation of thoracic cage movement and auscultation of gas entry .

28. Examination: C hest should be fully exposed and inspected for any signs of obvious injury. Presence of bruising, flail chest, penetration, and bleeding should be noted. The chest should be palpated for signs of rib or sternal fractures. Any subcutaneous emphysema should be appreciated. Chest expansion should be equal bilaterally, without intercostal or supraclavicular muscle retractions during respiration. The patient is assessed for inequalities in chest movement from one side to the other, crepitus and local movement asymmetry, as in paradoxic thoracic cage movement in flail chest.

29. CIRCULATION In the primary survey, circulation becomes the priority after airway and breathing have been definitively managed. The main cause of deaths that can be prevented is caused by hemorrhage. Shock in a trauma patient is primarily hypovolemic secondary to trauma, although the patient may present with cardiogenic, neurogenic, or even septic shock. Extensive damage to the CNS or spinal cord may result in a neurogenic shock.

30. ASSESSMENT Level of consciousness: Cerebral perfusion indicates an adequate circulating volume of blood Pulse: Rapid pulse may indicate blood loss whereas an irregular pulse may indicate cardiac d ysfunction . Respiratory rate : According to the degree of hemorrhage present, patients may become t achypneic as a physiologic response to the need for more oxygen to be delivered to the tissues. • Skin color: A gray, pale ashen tone may indicate hypovolemia; pink skin is an indication of good perfusion. • Urinary output: . A decrease of urinary output to less than 30 mL/ hr in an adult may indicate hypovolemia in the absence of other medical conditions (e.g., renal damage).

31. SHOCK Recognition of shock Tachycardia Skin colour Level of consciousness Respiratory rate Urine output

32. Management of bleeding in maxillofacial trauma

33. AMERICAN COLLEGE OF SURGEONS (2001), Classification of acute hemorrhage Committee on Trauma. Advanced Trauma Life Support Student manual. 6 th ed. Chicago. American College of Surgeons. 2001: 87-107.

34. Initial management of haemorrhagic shock External bleeding Occult bleeding The twin goals in resuscitation of the shock patient are prevention of further blood loss and the earliest restoration of tissue perfusion Posterior nasal pack Packing using foley’s

35. FLUID REPLACEMENT In a shocked, hypotensive patient, the aim of fluid resuscitation should be to restore critical organ perfusion until hemorrhage that is amenable to surgery is stemmed.

36. Indication of blood therapy Goal : the oxygen carrying capacity of blood. Indications Hb <6 gm% (normal =10 gm%) 4. Major surgical procedure 5. Anticipation of ongoin blood loss >100ml/min 6. Acute blood loss > 40% (2L crystalloid 3:1 ---  colloid 1:1 )

37. D : Disability A rapid evaluation is performed at the end of the primary survey, and this establishes the patient’s level of consciousness. A: Alert V: responds to Vocal stimuli P: responds to Painful stimuli U: Unresponsive to all stimuli

38. Neurologic evaluation is performed to establish the patient’s level of consciousness of the trauma & pupillary size & reaction. Quickly identifies any severe CNS problems that require immediate intervention or additional diagnostic evaluation. A more detailed quantitative neurologic examination is part of 2ndry survey of the trauma patient. A decrease in the level of consciousness may indicate decreased cerebral oxygenation or perfusion. Reactivity of pupils to light provides a quick assessment of cerebral function.pupils should react equally. Changes represent cerebral or optic nerve damage or changes in ICP.

39. E: EXPOSURE & ENVIRONMENTAL CONTROL

40. EXPOSURE Patients should be completely disrobed during the initial assessment and the subsequent secondary survey. This helps ensure the observation and assessment of significant injuries. At the same time, efforts to prevent significant hypothermia using a warm ambient room (82° to 86° F [28° to 30° C]), overhead heating, and warmed IV fluids, should be instituted. RAYMOND J. FONSECA; oral & maxillofacial trauma; fourth edition; 2013; Saunders; Elsevier

41. BLS B asic L ife S upport

42. General considerations Adult chain of survival

43. Step 1: Scene Safety and Assessment Step 2: Activation of emergency response system and AED BLS/CPR for adults

44. Step 3: Pulse check Step 4: CPR chest compression technique

45. Step 4: CPR opening the airway for breaths : head tilt chin lift

46. Jaw thrust technique 2 rescuer technique

47. AED for adults and children > 8 years Power on Attach Clear & Analyze Shock if advisable Immediately resume CPR Reanalyze after 2 min (5 cycles of CPR)

48. Rescue breathing Pulse Breaths Rescue breathing for adults Rescue breathing for infants & children Give 1 breaths every 5-6 sec (about 10-12 breaths/min) Give 1 breaths every 3-5 sec (about 12-20 breaths/min) Give each breath in 1 sec Each breath should result in visible chest raise Check the pulse every 2 min

49. MAXILLOFACIAL INJURIES Possible for maxillofacial injuries to result in airway compromise because of the following: Blood and secretions Mandibular fracture that allows the tongue to fall posteriorly against the posterior wall of the pharynx Midface injury that causes the maxilla to fall inferiorly and posteriorly into the nasopharynx Foreign debris, such as avulsed teeth or dentures. RAYMOND J. FONSECA; oral & maxillofacial trauma; fourth edition; 2013; Saunders; Elsevier

50. Maxillofacial Structures Examine the nose for deformity, pain, mobility, and difficulty in breathing, which suggest bony or cartilaginous fractures. Epistaxis and, in particular, CSF rhinorrhoea suggests an anterior cranial fossa fracture at the cranial base, the ears for hemotympanum and CSF otorrhea . Bleeding from the external auditory canal soft tissue wall may be secondary to mandibular condylar fracture with or without glenoid fossa injury Lastly, examination of the mouth is performed. Buccal vestibule(zygoma), the palate (maxilla), and the floor of the mouth(anterior mandible) is noted

51. Examination: Extra ora l: The face should be examined for asymmetry, discolorations, or swelling suggestive of bony or soft tissue injury. Eyelids should be elevated to examine for neurologic and possible ocular damage. All bony landmarks should be palpated for signs of crepitus, steps, or other irregularities. Palpation should include the supraorbital, lateral, and infraorbital rims, malar eminences, zygomatic arches, nasal bones, maxilla, and mandible. RAYMOND J. FONSECA; oral & maxillofacial trauma; fourth edition; 2013; Saunders; Elsevier

52. Examination: Intra oral: An oral cavity examination should include an evaluation of lost teeth, lacerations and alterations in the occlusion. Teeth avulsed at the time of injury must be accounted for because the tooth may have been inadvertently aspirated or swallowed.

53. CONCLUSION An efficient & systematic assessment of the trauma patient is imperative for timely diagnosis & management of the patient.

54. Refrences Peterson’s principles of Oral & Maxillofacial Surgery. (4 th edition) Oral and Maxillofacial Trauma, Volume 2. Raymond J.  Fonseca,Robert V. Walker Snippet view - 1991 . WILLIAMS, J. L., & ROWE, N. L. (1994).  Rowe and Williams' maxillofacial injuries . Edinburgh, Churchill Livingstone.

55. Thank You