AHRAM CANADIAN UNIVERSITY

Maxillofacial
Trauma
Lecture 1

ORAL AND MAXILLOFACIAL SURGERY DEPT

FACULTY OF DENTISTRY
AHRAM CANADIAN UNIVERSITY
 Maxillofacial trauma
Maxillofacial trauma is any injury to the face or jaws.
Injuries to the face can either occur in isolation, or they can be associated with
significant injuries elsewhere on the patient, some of which may also go unnoticed
initially.

Causes of maxillofacial trauma:

• Road traffic accidents (RTA).
• Falls.
• Interpersonal violence
• Sport related injuries.
• Work related injuries.

• War injuries

• Animal bites or kicks

Basic principles for treatment of trauma patient:

1. Preservation of life.
2. Maintenance of function.
3. Restoration of appearance.

Management of the trauma patient:

1- Initial management: general assessment of the patient to determine the need
for emergency treatment.
2- Diagnosis: Local clinical examination and Radiological examination.
3- Definitive treatment.
4- Post-operative care and follow-up.

Initial management of the trauma patient:

The accurate and systematic assessment of injury is essential to establish the extent of
injury to vital structures. This forms the basis of Advanced Trauma Life Support
(ATLS) protocols. It is estimated that approximately 25% to 30% of deaths caused by
trauma can be prevented when a systematic and organized approach is used.
Trauma patients should undergo an initial assessment and treatment that is prioritized
and corresponds to their injuries and stability of their vital signs. When critical injuries

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are present, lifesaving measures necessitate that a logical and sequential treatment
priority be established, based on the overall assessment of the patient.
Satisfactory outcomes for injured patients are strongly influenced by the initial care
delivered, particularly in the so-called ‘‘golden hour’’ following admission to the
hospital emergency department. For some patients, this period may be only minutes
(patients requiring a definitive airway), but for others, it may be measured in hours
(unstable bleeding, pelvic fracture). Approximately 60% of all trauma-related hospital
deaths occur during this crucial 1-h period. Inadequate assessment and resuscitation
contribute to a preventable death rate of as high as 35%.

Steps of the initial management:

These principles are involved in the initial assessment of a patient with major trauma
and have been outlined by the American College of Surgeons (ACS) in their guidelines
regarding ATLS protocols. These principles are as follows:

1.Primary survey and resuscitation.

2.Secondary survey,
3.Defnitive care.

1- Primary Survey (immediate assessment)

During the primary survey, life-threatening conditions are identified and reversed
quickly. Different conditions are frequently treated simultaneously. It could be carried
out in the prehospital or hospital phase or both.

A Airway: Maintaining oxygenation and preventing hypercarbia are critical. The

perfusion of the brain and other vital structures will mean the difference between life
and death, or permanent disability.
The first priority in treatment of the trauma patient is assessment and maintenance of
airway patency, adequate oxygenation, ventilation, and protection from aspiration.

Causes of airway obstruction:

• Bleeding from oral or facial structures.

• Aspiration of foreign materials.

• Vomiting.

• The position of the tongue, especially in the unconscious patient.

• Progressive swelling

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 • Some facial fractures. e.g. mandibular fracture that allows the tongue to fall
posteriorly against the posterior wall of the pharynx, or midface injury that
causes the maxilla to fall inferiorly and posteriorly into the nasopharynx.

Airway maintenance techniques:

• Chin lift
• Jaw thrust

Airway maintenance adjuncts:

• Oropharyngeal airway
• Nasopharyngeal airway
Definitive airway: defined as a tube placed in the trachea with cuff inflated below the
vocal cords to guard against aspiration and airway collapse and to supply supplemental
oxygen and assisted ventilation. This is carried by endotracheal intubation whether nasal
or oral (Nasotracheal or Orotracheal intubation).
Surgical airway: When intubation is not possible, such as edema of the glottis,
laryngeal fracture, or profuse hemorrhage, a surgical airway must be established. A
cricothyrotomy is preferred to a tracheotomy because it involves less time and is
associated with less bleeding.

Airway Assessment:
The strategy of look, listen, and feel helps to figure out airway obstruction and
anticipated breathing complications.
The airway management approach, particularly in unconscious trauma patients should
be complimented with the protection of C-spine by: Return head to neutral position -
Maintain in-line stabilization - Correct size collar application - Blocks/tape

B Breathing:
With establishment of an adequate airway, the pulmonary status must be evaluated.
▪ A talking patient is not at immediate risk of airway loss, but repeated assessment must
be done as airway loss can be progressive.
▪ Awake but combative patients who refuse to lay supine may be indicating their
inability to manage their airway in the recumbent position.
▪ Audible breathing, or stridor indicate partial airway obstruction.
▪ Hoarseness (dysphonia) implies functional laryngeal obstruction.
▪ Edema and/or hematoma of the neck is a sign of impending airway loss and should
lead to early intubation.
▪ Very slow or rapid rates of respiration usually suggest poor ventilation (normal resp.
rate is 12-16 breaths/min)
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If the patient is breathing spontaneously, confirmed by feeling and listening for air
movement at the nostrils and mouth, supplemental oxygen may be delivered by face
mask.
▪ The patient’s status should be re-evaluated constantly.
▪ If there is absence of breathing or signs of inadequate ventilation, a secure airway
should be placed (ideally an endotracheal tube) and assisted ventilation should be
started. ( bag valve mask or artificial respirator)

C Circulation:
• The rescuer should stop any visible hemorrhage using direct compression and
appropriate dressings.
• The main cause of deaths that can be prevented is caused by hemorrhage. It is
estimated that hemorrhage accounts for 30% to 40% of trauma mortality, with 35% to
65% of deaths occurring in the prehospital period; 50% of deaths secondary to
hemorrhage occur within the first 24 hours after the initial trauma.
• The most common cause of shock in the traumatized patient is hypovolemia caused
by hemorrhage, either externally or internally into body cavities, but the patient may
present with cardiogenic, neurogenic, or even septic shock.

Assessment of Circulation:
• The hemodynamic status (blood volume and cardiac output) should be assessed as
follows:
• Level of consciousness
• Pulse: The pulse should be checked in central arteries such as the femoral and
carotid arteries. Rapid pulse may indicate blood loss whereas an irregular pulse
may indicate cardiac dysfunction.
• Respiratory rate: According to the degree of hemorrhage present, patients may
become tachypneic as a physiologic response to the need for more oxygen to be
delivered to the tissues.
• Blood pressure: If the blood loss is significant (>30% of blood volume), there
will be changes in blood pressure.
• Skin color: A gray, pale ashen tone may indicate hypovolemia; pink skin is an
indication of good perfusion.
• Urinary output: Urinary output is considered to be in normal limits with
approximately 0.5 mL/kg/hr for the adult and 1mL/kg/hr for children. A decrease
of urinary output to less than 30 mL/hr in an adult may indicate hypovolemia.
A cool patient with tachycardia is considered to be in shock, until proven otherwise.

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Bleeding in maxillofacial trauma:
• Patients with multiple maxillofacial injuries must be taken care. Otherwise, they will
go into hemorrhagic shock.
• In the supine position, bleeding into oropharynx and swallowed blood in a conscious
patient may cause vomiting thus, risking the C-spine. the purpose of hemostasis in
maxillofacial trauma patient, is to protect the airway, and to reduce blood loss.
• Maxillofacial injuries are very prone to massive hemorrhages. Nasal or midface
fractures may hemorrhage from tears of the ethmoidal arteries that arise from the
internal carotid system or from branches of the maxillary artery system. Most
hemorrhages from facial injuries can be controlled with direct pressure or packing.
Internal maxillary artery bleeding from posterior maxillary wall fractures associated
with Le Fort I or II level fractures usually can be controlled by pressure with posterior
nasal packing.
• Sometimes, immediate reduction of fractures is mandatory to control bleeding from
the intraosseous branches.
• Ligation of the external carotid artery has been suggested, but this procedure is rarely
successful owing to the collateral blood supply.
Fluid resuscitation:
• Two large bore IV lines should be placed for replacing fluid loss. At the time of
placement of an intravenous catheter, blood should be drawn from the catheter to allow
for typing, cross-matching, and baseline hematologic and chemical studies. If there is
any doubt of adequate ventilation, arterial blood should be obtained for blood gas
analysis.

D DISABILITY:
• During the primary survey, a brief assessment of neurologic status should be
performed. A recommended system is the AVPU method:
A—Patient is awake, alert, and appropriate.
V—Patient responds to voice.
P—Patient responds to pain.
U—Patient is unresponsive. Fixed dilated pupils that are unresponsive to light may
indicate brain stem injury.
• During the secondary assessment, a more detailed assessment is done, mainly using
GCS (Glasgow coma scale) to identify the level of consciousness and complete the
neurological examination with cranial and peripheral nerves examination if needed.

E Exposure of the Patient:

• The patient should be completely disrobed so that all of the body can be visualized,
palpated, and examined for injuries or bleeding sites
Logroll the patient to examine patient’s back. Maintain cervical spinal immobilization
Palpate along thoracic and lumbar spine.

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 2- Secondary assessment:

• Reassessment of vital signs, complete history of the mechanism of injury, past medical
history, and a meticulous head-to-toe examination must be obtained in every trauma
victim following an appropriate response to the initial resuscitation.
• During the secondary assessment, the patient’s vital signs and condition should be
constantly monitored to evaluate the therapeutic interventions initiated during the
primary assessment and to further assess the patient for any other life-threatening
problems not evident during the primary survey.
• Obviously, the comatose patient cannot provide useful subjective information, but
family members, bystanders, or other victims may provide some details.
• For external hemorrhage, staples or sutures may be used to control bleeding.
• Treatment of internal hemorrhage can be initiated.
• Radiographic studies and further blood studies may be done at this time.
• Definitive treatment of different injuries should proceed according to their priorities.
• Orthopedic injuries (fractures) are often over looked initially and are treated at a later
time when the patient is stabilized.

3- Definitive care.

Transfer to Definitive Care

• Operating Room
• ICU
• Higher level facility