Emergency Care in Facial Emergency Care in Facial Trauma – A MaxillofacialTrauma – A Maxillofacial

and Ophthalmic Perspectiveand Ophthalmic Perspective

Injury, Int. J. Care Injured (2005) 36, 875—896Injury, Int. J. Care Injured (2005) 36, 875—896

Presented by intern Presented by intern 朱岑玲朱岑玲

IntroductionIntroduction

Aim:Aim: consider life- and sight- threatening consider life- and sight- threatening conditions that may occur following trauma to the conditions that may occur following trauma to the face.face.Life- and sight- threatening complications may Life- and sight- threatening complications may occur following apparently trivial injuries, which occur following apparently trivial injuries, which may not immediately be evident on arrival in the may not immediately be evident on arrival in the resuscitation or emergency setting.resuscitation or emergency setting.Assessment needs to be both systematic and Assessment needs to be both systematic and repeated.repeated.True maxillofacial and ophthalmic ‘‘emergencies’’ True maxillofacial and ophthalmic ‘‘emergencies’’ are uncommon.are uncommon.

Focused on any clinical problem that Focused on any clinical problem that requires immediate identification and requires immediate identification and management to preserve life, or sight.management to preserve life, or sight.

Facial injuries resulting in life threatening Facial injuries resulting in life threatening conditions include:conditions include:– airway compromiseairway compromise– profuse blood lossprofuse blood loss

ATLS and the Maxillofacial RegionATLS and the Maxillofacial Region

When managing facial injuries, this When managing facial injuries, this involves assessment and maintenance of involves assessment and maintenance of the airway and control of obvious the airway and control of obvious bleeding.bleeding.

The early identification of a sight-The early identification of a sight-threatening condition may be possible threatening condition may be possible during ‘‘D’’.during ‘‘D’’.

High index of suspicion; frequent re-High index of suspicion; frequent re-assessmentassessment

Airway with Control of C-SpineAirway with Control of C-Spine

Even in those patients who give an appropriate Even in those patients who give an appropriate response, this should still be followed by direct response, this should still be followed by direct inspection of the mouth and pharynx for loose, inspection of the mouth and pharynx for loose, or foreign, bodies, and signs of continuing or foreign, bodies, and signs of continuing bleeding.bleeding.Retropharyngeal haematomaRetropharyngeal haematoma cervical spine cervical spine injuryinjuryThe cervical spine should be immobilised, The cervical spine should be immobilised, unless the patient is agitated and extremely unless the patient is agitated and extremely restless.restless.

The most common obstructing materials The most common obstructing materials that threaten the airway in facial injuries that threaten the airway in facial injuries are are blood and vomitblood and vomit..

The potential for obstruction is present in The potential for obstruction is present in almost all patients with significant facial almost all patients with significant facial injuries, due to pooling of blood and injuries, due to pooling of blood and secretions in the pharynx, especially when secretions in the pharynx, especially when supine.supine.

Can I sit up?Can I sit up?

A desire to vomit, or unrecognized partial A desire to vomit, or unrecognized partial airway obstruction from swelling, loss of airway obstruction from swelling, loss of tongue support, or bleeding.tongue support, or bleeding.ATLS? based on a ATLS? based on a risk/benefit analysisrisk/benefit analysisWhen multi-system injury is obvious, or When multi-system injury is obvious, or suspected, attempts to sit up are even suspected, attempts to sit up are even more problematic and if the patient is more problematic and if the patient is combative, early intubation and ventilation combative, early intubation and ventilation may be necessary to secure the airway.may be necessary to secure the airway.

Whatever the circumstances, all efforts Whatever the circumstances, all efforts should be made to protect the cervical should be made to protect the cervical spine as best possible.spine as best possible.

Patients should never be forced, or Patients should never be forced, or restrained, onto their backsrestrained, onto their backs

The Significance of Fractures and The Significance of Fractures and Soft Tissue SwellingSoft Tissue Swelling

Loss of tongue support, significant soft Loss of tongue support, significant soft tissue swelling, and intraoral bleeding may tissue swelling, and intraoral bleeding may occur with bilateral, or comminuted, occur with bilateral, or comminuted, anterior mandibular fractures.anterior mandibular fractures.

Simple anterior mobile mandibular Simple anterior mobile mandibular fracturesfractures temporarily be reduced and temporarily be reduced and stabilizedstabilized reduces bleeding, swallow reduces bleeding, swallow more effectivelymore effectively

Combined mandibular and middle third facial Combined mandibular and middle third facial fractures: high risk of airway problemsfractures: high risk of airway problems regular and repeated assessments regular and repeated assessmentsSignificant soft tissue swelling usually occurs with Significant soft tissue swelling usually occurs with major ‘‘panfacial’’ injuries, often necessitating major ‘‘panfacial’’ injuries, often necessitating prolonged intubation, or planned elective prolonged intubation, or planned elective tracheostomy.tracheostomy.Fractures of the hyoid bone: a surrogate ‘‘marker’’ Fractures of the hyoid bone: a surrogate ‘‘marker’’ of significant injury and indicative of the risk of of significant injury and indicative of the risk of airway obstruction.airway obstruction.StridorStridor necessitates urgent intubation. necessitates urgent intubation.

The Anterior NeckThe Anterior Neck

A forgotten site!!A forgotten site!!

Between “A” and “B”Between “A” and “B”

History: wearing a motorcycle helmet, History: wearing a motorcycle helmet, strangulation, or contact sport injurystrangulation, or contact sport injury

A hoarse voice, haemoptysis, surgical A hoarse voice, haemoptysis, surgical emphysema, or fracture crepitus in the emphysema, or fracture crepitus in the neck are highly suggestive of such injuries neck are highly suggestive of such injuries and should actively be sought.and should actively be sought.

The Cervical SpineThe Cervical Spine

Several patterns of C-spine injury Several patterns of C-spine injury following facial trauma have been following facial trauma have been reported:reported:– Mandibular fr. and upper C-spine injuriesMandibular fr. and upper C-spine injuries– Mid facial injuries and lower C-spine injuriesMid facial injuries and lower C-spine injuries

little practical importance little practical importance

the best policy is to assume that spinal injury the best policy is to assume that spinal injury

is present is present

Airway Maintenance TechniquesAirway Maintenance Techniques

All trauma patients should receive oxygen.All trauma patients should receive oxygen.

With severe facial injuries, early With severe facial injuries, early involvement of an experienced anaesthetist involvement of an experienced anaesthetist is essential.is essential.

Several techniques exist for maintaining Several techniques exist for maintaining an airway:an airway:– SuctionSuction– Jaw thrustJaw thrust– Chin liftChin lift– Oro- or/ naso-pharyngeal airwaysOro- or/ naso-pharyngeal airways– Tongue sutureTongue suture– Laryngeal maskLaryngeal mask

Posteriorly displaced, middle third fractures may Posteriorly displaced, middle third fractures may be reduced manually to improve the airway.be reduced manually to improve the airway. additional benefit: controlling hemorrhage additional benefit: controlling hemorrhage

None of these adjuncts provides a None of these adjuncts provides a definitive and secure airway.definitive and secure airway.

Naso-pharyngeal airway, and naso-Naso-pharyngeal airway, and naso-gastric, or naso-tracheal tubes, are gastric, or naso-tracheal tubes, are generally regarded as generally regarded as contra-indicatedcontra-indicated in in mid face injuries, or in suspected skull mid face injuries, or in suspected skull base fractures.base fractures.

Vomiting Following Facial InjuriesVomiting Following Facial Injuries

Predisposing factors: food, blood in the stomach, Predisposing factors: food, blood in the stomach, alcohol intoxication and brain injuriesalcohol intoxication and brain injuriesWarning signs: repeated requests or attempts by Warning signs: repeated requests or attempts by the patient to sit upthe patient to sit upThe difficulty arises in deciding which patients The difficulty arises in deciding which patients are at high risk of pulmonary aspiration after are at high risk of pulmonary aspiration after vomiting and therefore need to be intubated.vomiting and therefore need to be intubated.Best managed by lowering the head of the Best managed by lowering the head of the trolley approximately 15—30 cms and applying trolley approximately 15—30 cms and applying high flow suction.high flow suction.

Definitive AirwayDefinitive Airway

Oro-tracheal intubation, naso-tracheal Oro-tracheal intubation, naso-tracheal intubation, surgical cricothyroidotomyintubation, surgical cricothyroidotomyOro-tracheal intubation with in-line cervical Oro-tracheal intubation with in-line cervical immobilisation is the technique of choice immobilisation is the technique of choice in the majority of cases.in the majority of cases.In the absence of midfacial, or In the absence of midfacial, or craniofacial, fractures: blind naso-tracheal craniofacial, fractures: blind naso-tracheal intubation, or fibreoptic assisted oro- and intubation, or fibreoptic assisted oro- and naso-tracheal intubationnaso-tracheal intubation

The only indication for creating a surgical The only indication for creating a surgical airway is failure to secure the airway.airway is failure to secure the airway.

Needle cricothyroidotomy and surgical Needle cricothyroidotomy and surgical cricothyroidotomycricothyroidotomy

Needle cricothyroidotomy may be used to Needle cricothyroidotomy may be used to provide some oxygenation while preparing provide some oxygenation while preparing for a surgical cricothyroidotomy.for a surgical cricothyroidotomy.

BreathingBreathing

In the context of isolated maxillofacial In the context of isolated maxillofacial injuries, breathing problems may occur injuries, breathing problems may occur following aspiration of teeth, dentures, following aspiration of teeth, dentures, vomit and other foreign materials.vomit and other foreign materials.

If teeth or dentures have been lostIf teeth or dentures have been lost chest chest X-ray and soft tissue view of the neck X-ray and soft tissue view of the neck

CirculationCirculation

Hypovolaemic shockHypovolaemic shock facial injuries are unlikely facial injuries are unlikely to be the sole cause and a careful search made to be the sole cause and a careful search made elsewhere for occult bleeding.elsewhere for occult bleeding.

‘‘‘‘Severe’’ facial haemorrhage has been reported Severe’’ facial haemorrhage has been reported to occur in approximately 1 in 10 serious facial to occur in approximately 1 in 10 serious facial injuries.injuries.

Bleeding from comminuted fractures and soft Bleeding from comminuted fractures and soft tissue injuries can contribute to hypovolaemia tissue injuries can contribute to hypovolaemia and should be considered in all facial fractures.and should be considered in all facial fractures.

Vision-Threatening InjuriesVision-Threatening Injuries

Retrobulbar hemorrhageRetrobulbar hemorrhage

Traumatic optic neuropathyTraumatic optic neuropathy

Open and Closed globe injuriesOpen and Closed globe injuries

Loss of eyelid integrityLoss of eyelid integrity

Chemical injuryChemical injury

Retrobulbar HemorrhageRetrobulbar Hemorrhage

A compartment syndrome within the orbitA compartment syndrome within the orbitRaised intra-orbital pressure is caused by Raised intra-orbital pressure is caused by bleeding and associated oedemableeding and associated oedema compresses the ophthalmic and retinal compresses the ophthalmic and retinal vesselsvessels retinal ischaemia retinal ischaemiaA convenient time rapidly to assess the eyes is A convenient time rapidly to assess the eyes is when the pupils are assessed as part of the when the pupils are assessed as part of the GCS. GCS. Pain, proptosis, loss of visionPain, proptosis, loss of vision and the and the presence of an presence of an afferent pupillary defectafferent pupillary defect are the are the principal features for which to look.principal features for which to look.

In those patients in whom visual loss may be In those patients in whom visual loss may be reversible, and who are well enough, the reversible, and who are well enough, the management of retrobulbar haemorrhage is management of retrobulbar haemorrhage is surgical. (to decompress the orbit)surgical. (to decompress the orbit)

Medical treatments and a lateral canthotomy:Medical treatments and a lateral canthotomy:– High-dose intravenous steroids, acetazolamide High-dose intravenous steroids, acetazolamide

(250-500 mg) and mannitol (1 g/kg) are started before (250-500 mg) and mannitol (1 g/kg) are started before surgery and continued after surgery until the globe surgery and continued after surgery until the globe pressure is seen to be falling.pressure is seen to be falling.

Traumatic Optic NeuropathyTraumatic Optic Neuropathy

Deceleration injuries and blunt trauma Deceleration injuries and blunt trauma (motor vehicle collisions, falls and (motor vehicle collisions, falls and assaults) to the face and head are assaults) to the face and head are common causes of traumatic optic common causes of traumatic optic neuropathy.neuropathy.

When the eye appears normal, but there is When the eye appears normal, but there is reduced visionreduced vision and an and an afferent pupillary afferent pupillary defectdefect, injury to the nerve near the optic , injury to the nerve near the optic canal should be suspected.canal should be suspected.

Treatment is controversial and may be Treatment is controversial and may be medical, or surgical:medical, or surgical:– Intravenous methylprednisoloneIntravenous methylprednisolone– surgical decompression is generally reserved surgical decompression is generally reserved

for patients who fail to respond to steroid for patients who fail to respond to steroid treatment, in whom visual recovery is felt treatment, in whom visual recovery is felt possiblepossible

Open and Closed Globe InjuriesOpen and Closed Globe Injuries

‘‘‘‘Open’’: a full thickness wound in the Open’’: a full thickness wound in the corneo-scleral wall of the eyecorneo-scleral wall of the eye

‘‘‘‘Closed’’: does not have a full thickness Closed’’: does not have a full thickness wound in the eye wall wound in the eye wall

Bad prognosis:Bad prognosis:– A poor initial visual acuityA poor initial visual acuity– A relative afferent pupillary defectA relative afferent pupillary defect– Posterior involvement of the eye Posterior involvement of the eye

Open globe injury:Open globe injury:– Bloodstained tearsBloodstained tears– The eye looks collapsed The eye looks collapsed

and uveal tissue, retina and and uveal tissue, retina and the vitreous gel may be the vitreous gel may be seen prolapsing out of the seen prolapsing out of the eyeeye

– The intra-ocular pressure is The intra-ocular pressure is lowlow

– Tx: Primary surgical repair Tx: Primary surgical repair as soon as possible and no as soon as possible and no later than within 24 h after later than within 24 h after trauma.trauma.

Closed globe injury:Closed globe injury:– the globe looks formed and the intra-ocular the globe looks formed and the intra-ocular

pressure is usually highpressure is usually high– Tx: steroid, antibiotic, cycloplegic and anti-Tx: steroid, antibiotic, cycloplegic and anti-

hypertensive eye dropshypertensive eye drops

Loss of Eyelid IntegrityLoss of Eyelid Integrity

Inability effectively to close the eyelids rapidly Inability effectively to close the eyelids rapidly results in desiccation of the cornea, ulceration results in desiccation of the cornea, ulceration and potentially loss of sight.and potentially loss of sight.

In the presence of eyelid lacerations, In the presence of eyelid lacerations, assessment and management of the underlying assessment and management of the underlying globe is more important than that of the eyelid.globe is more important than that of the eyelid.

Visual acuity, visual fields, colour vision, ocular Visual acuity, visual fields, colour vision, ocular movement, the pupil and the fundus should be movement, the pupil and the fundus should be examined in all patients with eyelid lacerations.examined in all patients with eyelid lacerations.

The timing of surgery depends on the The timing of surgery depends on the general condition of the patient and the general condition of the patient and the presence of other injuries. Repair of lid presence of other injuries. Repair of lid lacerations can safely be deferred for up lacerations can safely be deferred for up to 48 h.to 48 h.

Chemical InjuryChemical Injury

Chemicals that have a pH different from Chemicals that have a pH different from that of the eye (pH 7.4) can cause a burn. that of the eye (pH 7.4) can cause a burn. Alkalis cause more damage than acids, as Alkalis cause more damage than acids, as they break down lipid membranes and they break down lipid membranes and penetrate deeper.penetrate deeper.The greater the pH difference, the more The greater the pH difference, the more concentrated the solution and the longer concentrated the solution and the longer the contact time, the more damage is the contact time, the more damage is caused.caused.

All eyes must receive local anaesthetic All eyes must receive local anaesthetic drops, pH evaluation and irrigation with drops, pH evaluation and irrigation with copious amounts of Ringer lactate (at copious amounts of Ringer lactate (at least 2 L)least 2 L)

ConclusionsConclusions

Life- and vision-threatening maxillofacial Life- and vision-threatening maxillofacial emergencies are uncommon. However, they do emergencies are uncommon. However, they do occur in well-defined high risk groups and, as occur in well-defined high risk groups and, as such, it is important that clinicians such, it is important that clinicians maintain a maintain a high index of suspicionhigh index of suspicion and treat these and treat these emergencies accordingly. emergencies accordingly. The best outcome for these traumatised patients The best outcome for these traumatised patients is associated with treatment by a is associated with treatment by a multi-multi-disciplinary trauma teamdisciplinary trauma team, which includes a , which includes a maxillofacial surgeon who has experience of maxillofacial surgeon who has experience of these conditions.these conditions.