Early Assessment and Treatment Planning of the Maxillofacial Trauma Patient
Advanced Trauma Life Support (ATLS) has been recognized as the gold standard for the initial management of multiple injured patients. Although the priority of maxillofacial injuries is usually subordinated to more critical, life-threatening injuries, the role of the maxillofacial surgeon in the primary and secondary surveys of patients with maxillofacial injuries should be emphasized.
The treatment of patients with maxillofacial injuries can be managed by a maxillofacial trauma team if the injuries are isolated to the maxillofacial area or by a designated hospital trauma team. Although initial diagnosis and emergency treatment (e.g., controlling hemorrhage) are intuitive even to the novice, the experienced surgeon will remember that significant injuries can be missed after initial management of the trauma patient. The incidence of missed injuries after trauma has been reported to range from 8% to 65%.1 Missed injuries are especially likely when the mechanism of injury has caused substantial internal damage, as can be the case with decelerating injuries, for example. All members of the treatment team should assume the responsibility of constant patient reassessment.
• Immediate, resuscitative, or emergent treatment required: Facial injuries that are life-threatening (causing airway obstruction or severe hemorrhage) or sight-threatening (causing increases in intraocular pressure) and that require immediate interventions aimed at securing the airway, stopping the hemorrhage, or relieving the intraocular pressure via cantholysis.
Details of the ATLS primary survey are discussed elsewhere in this text. The goal of this section is to highlight the role of the maxillofacial surgeon in the ABCDEs. This role is often crucial and includes life-preserving and sight-preserving procedures. A few examples are detailed here.
If a patient has an unfavorable bilateral mandibular fracture causing airway obstruction, the maxillofacial surgeon can assist by simply stabilizing the fracture with a bridle wire. By restoring spontaneous breathing, this maneuver may eliminate the need for endotracheal intubation.
If the patient’s Glasgow Coma Scale score is lower than 15, performing a procedure to stabilize a bilateral mandibular fracture will permit the patient to breathe spontaneously and will reduce the likelihood of airway obstruction if the patient’s level of consciousness decreases. This procedure will allow the patient to breathe and ventilate without the aid of an advanced airway; in turn, the absence of endotracheal intubation allows neurologic assessment of the patient at regular intervals.
The face and neck are heavily vascularized regions of the body and this large blood supply facilitates a level of healing that is unmatched elsewhere in the body. On the other hand, however, this robust vascularity means that injuries to this region of the body can produce copious bleeding that requires immediate attention. A few key examples follow.
The connective tissue layer of the scalp contains a rich, subcutaneous vascular supply. A laceration to the scalp can cause the loss of a large amount of blood and result in hypovolemic or hemorrhagic shock. Occasionally, the scalp is an occult source of hemorrhage. When a patient is in shock and the blood pressure is low, bleeding from a scalp wound is not obvious. Once resuscitation has been performed and the blood pressure has increased, however, bleeding will begin again and will become difficult to control. Thus it is necessary for scalp lacerations to be stabilized before any interhospital transfers or lengthy diagnostic procedures are performed.2 The deleterious events that may follow a scalp hemorrhage should not be underestimated.
Scalp lacerations can be most rapidly stabilized with Raney clips, which should be available in emergency trauma bays and in operating rooms. Other potentially useful temporary stabilizing measures are staples and sutures.
Epistaxis is a serious problem that may lead to airway obstruction, aspiration, shock, and exsanguination if not recognized and managed early. Many cases of unrecognized and untreated fatal epistaxis have been reported.3–5 The most frequent cause of massive hemorrhage among patients with facial trauma is midface fractures, which typically cause epistaxis with bleeding through the oral cavity.6 Control of a massive and a potentially lethal epistaxis consists of the following:
Posterior nasal packing is best performed with a 14-, 16-, or 18-Fr Foley catheter with a 10-mL balloon. The tip of the catheter is inserted through the nostril and is advanced until it is seen through the nasopharynx. This visualization is a crucial step, because the balloon of the catheter should not be inflated at the base of the skull. The catheter is then tugged forward to tamponade bleeding in the posterior nasal cavity. Bilateral posterior packs may be necessary. The catheter should be sutured or tied anteriorly so that posterior advancement and aspiration can be prevented.
The anterior nasal packing material is standard half-inch gauze moistened with bacitracin (or petrolatum gauze) placed in an overlapping fashion, beginning at the floor of the nose and extending superiorly.
Two ready-made commercial packing systems can control bleeding more rapidly than traditional packing, the Nasostat epistaxis balloon (Sparta, Pleasanton, Calif) and the Storz epistaxis catheter (Storz, St. Louis).
Packs should remain in place for no more than 24 hours; antibiotic coverage is recommended so that serious infections can be avoided. If packs are needed for more than 24 hours, they should be changed daily.
If interventional radiology is unavailable, surgical exploration and ligation of the affected vessels may be necessary—transantral ligation of the maxillary artery or its terminal branches; ligation of the anterior or posterior ethmoid arteries through the medial orbital wall
Although historically the ligation of the external carotid artery has been described, the collateral circulation is very rich, and ligation of the external carotid artery will not always stop the hemorrhage.
Bleeding from the oral cavity can typically be managed temporarily with packing and pressure. Severe hemorrhage can indicate that the inferior alveolar vascular bundle has been severed. Applying a bridle wire or an arch bar (with or without maxillomandibular fixation) will stop the bleeding or substantially reduce it.
Ocular examination is a routine part of the primary survey and includes pupil size, reactivity to light, and symmetry. In addition, the examiner should rule out a relative afferent pupillary defect (RAPD, or Marcus Gunn pupil) and palpate the globe (hard or soft).7 These elements of the eye examination can be performed quickly and easily and yield a large amount of information.
It can be difficult to obtain a history from the trauma patient; often, information must be gathered from the prehospital personnel and the patient’s family members. The following points should be addressed when the history is obtained (AMPLE is a familiar mnemonic)7:
Intuitively, a knowledge of the patient’s medical history, medications, and allergies helps determine whether modifications in management may be necessary. The last meal and pregnancy status of the female patient are important pieces of information, primarily as they relate to possible timing of surgery and to the evaluation and safety of the fetus.
Certain mechanisms of injury should produce a high level of suspicion for distinct types of trauma. For example, a history of a decelerating injury (restrained passenger in a motor vehicle accident [MVA]) should lead to a high suspicion of serious life-threatening consequences caused by shearing forces (e.g., lung or aortic injuries).7 Knowledge of the mechanism of injury also assists the surgeon in identifying specific maxillofacial injuries. Blunt injuries to the midface, for example, should prompt the performance of a thorough orbital examination and appropriate radiologic imaging for a proper diagnosis.
When the trauma patient is awake and oriented, a detailed review of systems (ROS) is invaluable because it directs the examiner’s attention to the site and type of injury. Many physical examination textbooks provide examples of various methods for completing the ROS; every provider should develop and follow his or her own routine to avoid missing important information.
A full-body review of systems should be performed. Table 11-1 is a suggested sequence for performing a head and neck ROS. The ROS allows the inference of various levels of severity of injuries. If the patient has a history of clear discharge from the nose (rhinorrhea) or ears (otorrhea), a fracture of the base of the skull should be suspected until ruled out. If the patient has a history of loss of consciousness, amnesia, vomiting, headaches, or seizure activity after the traumatic incident, a traumatic brain injury should be suspected and a neurosurgical consultation should be requested. Loss of vision or change in visual acuity is another serious symptom that should prompt rapid intervention and consultation with ophthalmology. If the patient reports a change in the dentition or occlusion that is associated with pain and limited mouth opening, a mandibular fracture should be suspected.
|Head, CNS||Headaches, nausea, vomiting, loss of consciousness after trauma, weaknesses in limbs, numbness, dizziness|
|Eyes||Change in visual acuity, double vision, pain, pulsatile eye|
|Ears||Changes in hearing acuity, ringing in ears, history of discharge or bleeding from the ear after trauma, dizziness, pain|
|Nose||Discharge or bleeding from nose after trauma, pain|
|Oral cavity||Change in bite, pain, limited mouth opening, bleeding, teeth missing as result of trauma|
|Neck||Tenderness in cervical spine region, throat pain, voice change, pain on swallowing|
|Cranial nerves||Numbness or weakness of particular area of face|
Treatment indicated for soft tissue wounds depends on the type of injury. Abrasions and contusions are usually treated with wound cleansing or observation, whereas lacerations or avulsive injuries may need more advanced repair. Attention should be paid to all areas of the scalp; wounds to the back of the head in a patient with long hair can be easy to miss.
The degree of wound contamination and the wound contaminant should be considered during the examination of facial soft tissue injuries. Facial wounds can be classified as clean or contaminated, depending on the wounding agent. The most recent guidelines for tetanus vaccination and booster doses should be followed.8
Bleeding is often associated with facial soft tissue trauma. Definitive repair of these wounds should be deferred until the trauma examination has been completed and a comprehensive treatment plan has been created. Some lacerations could be used as access to facial fracture repair.
Injuries to the forehead can be easily recognized and may indicate frontal bone fractures. The soft tissue overlying the frontal bone should be examined and special attention should be paid to the closure of any lacerations involving the hairline or the eyebrows.
The naso-orbital-ethmoid (NOE) complex must be systematically inspected during the physical examination. A missed NOE fracture can lead to serious aesthetic consequences that cannot be easily corrected by revision surgical procedures. Because the NOE complex is rarely fractured in isolation, the examination of this area is complex.
NOE fractures will be accompanied by ecchymosis and edema in the periorbital region and eyelids; subconjunctival hemorrhage may also be seen. If the NOE fracture occurs in combination with other facial fractures, edema and ecchymosis are generalized. NOE fractures produce a depression in the nasal bridge, causing the nose to appear short and retruded. Because telecanthus (increased intercanthal distance) is indicative of an NOE fracture, the intercanthal distance should be measured when an NOE fracture is suspected. This distance varie/>