Slide 1
Preparation and TRIAGEThe used of the following protective devices is recommendedGogglesGlovesFluid-impervious gowns or apronsShoes covers and fluid- impervious leggingsMaskHead coveringPRIMARY SURVEYA : Airway with cervical spine protect.B : BreathingC : Circulation --control external bleeding.D : Disability or neurological statusE : Exposure (undress) & Environment (temp control)
1/006RESUSCITATIONA. Airway*definite airway if there is any doubt about the pts ability to maintain airway integrity.
B. Breathing /Ventilation/Oxygenation*every injured pt should received supplement oxygen
C. Circulation*control bleeding by direct pressure or operative intervention* minimum of two large caliber IV should be established*pregnancy test for all female of child bearing age.* Lactated Ringer is preferred & better if warm.
1/0012PreparationA. Pre-hospital phase Receiving hospital is notified first. Send to the closest, appropriate facility.B In Hospital Phase Advanced planning for the trauma pt arrival. Method to summon extra medical assistance Transfer agreement with verified trauma center established. Protect from communicable disease.
1/004TRIAGEA Multiple Casualties no of severity & px do not exceed the ability of the facility.
B Mass Casualties no & severity of pt EXCEED the capability of the facility & staff.1/005Adjunct to the Secondary Survey hemodynamic statusCT scanContrast x-ray studiesExtremity x-rayEndoscopy and USG.1/00261/007PRIMARY SURVEYPriorities for the care of Adult , Pediatrics & Pregnancy women are all the same.During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.
A. Airway Maintenance with Cervical Spine Protection.GCS score of 8 or less require the placement of definite airway.Protection of the spine & spinal cord is the important management principle.Neurological exam alone does not exclude a cervical spine injury.Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or blunt injury above the clavicle.
1/0081/009B. Breathing & Ventilation* Airway patency does not assure adequate ventilation.C. Circulation with Hemorrhage Control. 1. Blood Volume & Cardiac Output a. level of consciousness. b. skin color c. Pulse. 2. Bleeding *external bleeding is identified & controlled in the primary survey. *Tourniquets should not be use.1/0010D. Disability ( Neurological Evaluation)Simple Mnemonic to describe level of consciousnessA : AlertV : Responds to Vocal stimuliP : Responds to Painful stimuliU : Unresponsive to all stimuli
Do Not forget to use also Glascow Coma Scale.
1/0011 E. Exposure / Environmental Control*It is the pts body temp that is most important, not he comfort of the health care provider.*Intravenous fluid should be warm. *Warm environment (room tem) should be maintained.*early control of hemorrhage.
C. Monitoring 1. Ventilatory rate & ABG 2. Pulse oximetry does not measure ventilation or partial O2 pressure 3. Blood pressure poor measure of actual tissue perfusion. D. X-Ray & Diagnostic Studies C-spine, CXR, Pelvic film, DPL/FAST Essential x-ray should not be avoid in pregnant pt.
*** Consider the need for patient transfer1/0014SECONDARY SURVEYHead to Toe evaluation & reassessment of all vital signs.A complete neurological exam is performed including a GCS score. Special procedure is order.
HISTORY1/0017A : Allergies.M: Medication currently used. P : Past illness/ Pregnancy. L : Last Meal E: Events/Environment related to the injury. *blunt trauma/penetrating trauma/injuries due to cold & burn/hazardous environment?PHYSICAL EXAMINATION Complete neurologic examinationHead and skullMaxillofacialNeck ChestAbdomenPerineum/rectum/vaginaMusculoskeletalTubes and fingers in every orificeNeurologic examination
HEAD Scalp Fractures Eyes edema- Pupil size - Penetrating injury Hemorrhage of conjunctivae, fundus Contact lenses - Dislocation of lenses Ocular entrapment Head
1/0020Other Physical Examination2. Maxillofacial Injury airway obstruction , major bleedingEx. of mid maxilla beware of NG tube insertionneed frequent reassessment
1/0021Other Physical Examination3. Cervical Spine & NeckHead injury pt. keep in mind of cervical spine injuryAbsence of neurologic deficit does not exclude spine injuryInspection , palpation , auscultation , cervical spine tenderness , subcutaneous emphysema , tracheal deviation , laryngeal fractureProtection of C-spine injury , helmet removingOther Physical Examination4. Chest Visual evaluation of anterior and posterior chest open pneumothorax flail chestPain , dyspnea , hypoxiaCardiac tamponade , tension pneumothorax distended neck veins distant heart sound
Other Physical Examination5. Abdomen excessive manipulation of the pelvic should be avoided.6. Perineum/rectum/vaginacontusion , hematoma , laceration , urethral bleeding rectal examination : blood , high-riding prostate , integrity of rectal wall , sphincter tonefemale : Vg exam.: blood , Vg laceration pregnancy test
1/0024Other Physical Examination7. Musculoskeletalinspection : contusion , deformitypalpation : tenderness , abnormal movementPelvic : ecchymosis on iliac wings , pubis , labia , scrotum , pain on palpation of pelvic ring assessment of peripheral pulsespatients back examinationDefinitive CareAfter identifying the patients injuries Managing life-threatening problemsObtaining special studiesTransfer If the patients injuries exceed the institutions treatment capabilities1/0029Indication For Definite Airway* Unconscious* Severe maxillo-facial fracture* Risk for aspiration : Bleeding/ vomiting* Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor* Apnea : Neuromuscular paralysis/unconscious* Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis* Severe closed head injury need for hyperventilation
1/0030Color Codes Triage Tag RED : Most critical injury YELLOW : Less critical injured GREEN : No life or limb threatened injury BLACK : Death or obviously fatal injury
1/0031Priorities with multiple injuries
1.Thoracic trauma or tamponade2.Abdominal hemorrhage3.Pelvic Hemorrhage4.Extremity Hemorrhage5.Intra-cranial Injury6.Acute Spinal Cord InjuryMaxillofacial TraumaEtiology and Incidence Multi system injury 20-50%Nasal and mandibular fractures most common in community EDsMidface and zygomatic injuries most common in Trauma centers25% of women with facial trauma result of domestic violenceIncidence of concomitant cervical spine injuries with facial fractures
Etiology and IncidenceOlder age, MVC and TBI-higher incidence
Facial fractures-a distracting injury?
Carotid artery injury
Blindness may occur with facial fracturesMaxillofacial Trauma
Emergency Management and ResuscitationAirwayMost urgent complication-Airway compromiseSimple interventions firstNo mandible?IntubationAvoid nasotracheal intubationMay not want RSIBenzodiazepinesKetamineEtomidateBe Prepared and Be Creative
Emergency Management and ResuscitationAirway Management OptionsAwake intubationLaryngeal Mask AirwayFiberoptic intubationLateral or semi-prone positionPercutaneous transtracheal jet ventilationRetrograde intubationCricothyroidotomyEmergency Management and ResuscitationHemorrhage ControlRarely develop shock from facial bleeding aloneDirect PressureLeFort FracturesNasal hemorrhage may require A&P packingHistoryVisionTeeth alignmentAbuse Maxillofacial Trauma-Physical ExamInspectionFacial elongationHigh grade LeFort FractureAsymmetryDeformities and cranial nerve injuryPalpationTendernessStep offsFacial stability
CrepitusSubcutaneous airCutaneous anesthesia
Maxillofacial Trauma-Physical ExamPeriorbital and Orbital ExamPerform early
Professional Lid RetractorMaxillofacial Trauma-Physical ExamPeriorbital and Orbital ExamLook for exophthalmos or enophthalmosPupil shapeHyphemaVisual acuityEntrapment signsRaccoon sign
Bimanual Palpation Test
Maxillofacial Trauma-Physical ExamPenetrating InjuriesOccult globe penetrationEyelid lacerationsNoseSeptal hematomaCSF RhinorrheaEarsSubperichondral hematomaHemotympanumBattle signMaxillofacial Trauma-Physical ExamOral and Mandibular ExamMandible deviationTeeth malocclusionParesthesiaTongue Blade Test95% Sensitive65% Specific
Maxillofacial Trauma-ImagingHead, chest and abdominal trauma takes precedencePE detects up to 90% of fracturesPlain FilmsCTOrbital fractures3D images availableMaxillofacial Trauma-Specific FracturesFrontal Sinus/Bone FracturesDirect blowFrequent intracranial injuriesMucopyocelesConsult with NS for treatment, disposition and antibioticsNasoethmoidal-Orbital InjuriesLacrimal apparatus disruptionBimanual palpation if medial canthus painCT faceMaxillofacial Trauma-Specific FracturesOrbital FracturesUsually through floor or medial wallEnophthalmosAnesthesiaDiplopiaInfraorbital stepoff deformitySubcutaneous emphysema
Maxillofacial Trauma-Specific FracturesOrbital Fissure SyndromeFracture of the orbital canalExtraocular motor palsies and blindnessIf significant retrobulbar hemorrhage, may need cantholysis to save visionZygomatic FracturesTripod fractureMost seriousLateral subconjunctival hemorrhageNeed ORIF
Arch fractureMost commonOutpatient repairTripod Fracture
Maxillofacial Trauma-Specific FracturesMaxillary FracturesHigh-energy injury100x gravityMalocclusionFacial lengtheningCSF rhinorrheaPeriorbital ecchymosis
LeFort Fractures
Maxillofacial Trauma-Specific Facial FracturesMandibular FracturesSecond most common facial fractureOften multipleMalocclusionIntraoral lacerationsSublingual ecchymosisNerve injury
Plain filmsPanorexCT
Open FracturesPen G or CleocinBody30-40 %Angle25-30 %Condyle15-17 %Symphysis7-15 %Ramus3-9 %Alveolar2-4 %Coronoid Process1-2 %
Lecture QuestionsWhat portion of the mandible is most commonly fractured?RamusCoronoid processBodyAngleSymphysisOrbital fractures can cause all of the following except:BlindnessMotor palsiesFacial anesthesiaEnophthalmosHyphema
Which of the following is/are true regarding maxillary fractures?Only minimal force necessaryRarely cause CSF rhinorrheaMay cause facial lengtheningUsually the only sustained injuryAll of the above are true
The best modality for diagnosing an orbital or facial fractures isPlain filmsMRICTUltrasoundOsteopathic palpationWhich statement below is correct?Midface fractures usually have minimal morbidityThe tongue blade test is quite sensitive in assessing need for mandibular xraysThe bimanual nasal exam is crucial in possible medial orbital wall fractureMidface fracture is an indication for nasotracheal intubation and RSI is often needed in these patientsc, e, c, c, bTHANK YOU