Maxillofacial Trauma

Front 1

 Most common cause:

Back 1

MVC

Front 2

 Most common bone:

Back 2

jaw

Front 3

 Rural:

Back 3

animal accidents and zygomatic fracture

Front 4

 Urban:

Back 4

nasal fracture  50% had other injuries

Front 5

Mechanism of Injury`

Back 5

• Blunt • Penetrating MVC Assaults GSW Falls Work/play without eye protection (eye)

Front 6

Assessment

Back 6

Primary survey is always PRIMARY Life saving measures, THEN eyes

Front 7

Primary Survey Airway Obstruction  Causes  Treatment

Back 7

 Teeth-check if they have any missing(xray if you cant find them)  Tongue  Foreign objects  Hemorrhage

Front 8

Impaired Ventilation
Emergent Airways

Back 8

Endotracheal intubation - ORAL
Nasotracheal intubation
Cricothyrotomy (surgical or needle)-ER-landmark and speed are advantage
Tracheostomy (surgical or percutaneous)-OR-lower so slower

Front 9

Hemorrhage treatment

Back 9

Direct pressure
Ice-dec edema prior to surgerical repair
Packing
Fracture reduction
Ligation of arteries / veins
IV

Front 10

Maxillofacial Assessment
Palpate facial structures

Back 10

Step offs
Irregularities
Crepitus
Nasal bones
Midface stability

Front 11

Maxillofacial Assessment

Eye exam

Ear

Back 11

Visual acuity, pupils, symmetry, EOM
Racoon eye-basilar skull fracture

Drainage

Front 12

Functional Disturbances r/t Facial Fractures

Back 12

nerves

Vision
Smell
Nasal breathing
Facial sensation
Perception of bite relationship

Front 13

Radiologic

Back 13

•Computed Tomography w/o contrast
–Fracture, Foreign Body, Air
•Computed Tomography Angiography
–Vascular compromise
•Panorex x ray-not common in ER
•MRI-non-emergent

Front 14

Bedside testing

Back 14

•Woods lamp-blacklight with magnifying glass to look in eye
–Foreign body, corneal abrasion, globe rupture
•Slit lamp exam
Seidel’s sign
•Snellen
•Tono pen-pressure 10-20 norm. over 20 monitor

Front 15

Soft Tissue Injury

Back 15

Goal: maintain function; good cosmesis

Lacerations
Abrasions
Contusions

Front 16

Soft Tissue Injury

Clean

Back 16

Soap, water, saline – NO DETERGENT, PEROXIDE, IODINE

Front 17

Soft Tissue Injury

Bites

Back 17

RATS – rabies, abx, Td, soap

Front 18

Soft Tissue Injury

Road rash / gunpowder
”

Back 18

Debridement ASAP to prevent permanent “tattoo

Front 19

Soft Tissue Injury

Eyebrow

Back 19

Repair before edema
Never shave

Front 20

Soft Tissue Injury

Cheek

Back 20

Deep lacs can cause damage to parotid gland, duct or branches of facial nerve

Front 21

Ear Injuries

Back 21

Hematoma-cauliflower-drain
Laceration-repair
Avulsion-shearing force-no clean edges-skin graft with plastic surgery

Front 22

Nasal Fracture

•Associated injuries

Back 22

•Ethmoid and frontal sinus fracture, damage to lacrimal duct, cribiform plate fracture and CSF leak (risk infection in brain), septal hematoma (block airway=emergency)

Front 23

Nasal Fracture

•Treatment:

Back 23

–Stop bleeding
–Pressure, ice, packing
–Reduction of fracture

Front 24

Nasal Fracture

______ is an emergency complication of a nasal fracture

Back 24

septal hematoma

Front 25

Epistaxis

•Treatment:

Back 25

–Posterior nasal packing
–Pack anterior nasal passage
–Pack the antra (maxillary sinus fracture)
–Pack the arch and palate
–Wrap gauze roll around the midface to compress the facial structures and packings

Front 26

Le Fort I-know

Back 26

Separates lower maxilla, hard palate, and pterygoid process in a single or comminuted unit

teeth will move but nose and eyes wont move

mustache break

can be unilateral

Front 27

Le Fort II-know

Back 27

Separation along the nasofrontal suture, orbit floor zygomatico-maxillary suture

when pressure on teeth=teeth and nose move orbit intach

Front 28

Le Fort Fracture Signs and Symptoms

Back 28

Facial pain
Anesthesia/paresthesia of upper lip-facial nerve issue
Visual disturbances-pressure-tearing of nerves/muscle
Facial swelling
Ecchymosis
Periorbital / orbital swelling
Subconjunctival hemorrhage
Elongation of face
Facial asymmetry
Epistaxis
Malocclusion

Front 29

Le Fort Fracture Management PRIMARY

Back 29

Airway control
Anticipate cricothyroidotomy or tracheotomy
Frequent suctioning with tonsil tip catheter
Position upright and leaning forward-promote drainage/dec swelling
Ice

Front 30

Le Fort Fracture Management
SECONDARY

Back 30

Reduction of fragments and stabilization with plates and screws
Jaws may be wired
Protect airway
Reduce risk of emesis / aspiration
OG tube
HOB 30 degrees
Have wire cutters at bedside

monitor eye movement and nerves

Front 31

Zygoma Fracture
1.Zygomatic arch
2.Tripod
Signs / symptoms

Back 31

Swelling
Ecchymosis of malar (cheek) and periorbital areas
Palpable infraorbital rim step off
Entrapment of extraocular muscles-see with EOM movement
Scleral ecchymosis
Double vision
Anesthesia of upper lip, cheek, teeth, gums

Front 32

Zygoma Fracture BONES

Back 32

1.Zygomatic arch
2.Tripod

Front 33

Orbit Fracture

•Signs / Symptoms

Back 33

Anesthesia of cheek and upper lip
Ptosis

Diplopia

–Periorbital ecchymosis
–Subconjunctival hemorrhage
–Periorbital edema
–Upward gaze
Orbital pain
Enophthalmos
Dysconjugate gaze
Hyphema
Subluxation of lens
Retinal detachment

Front 34

Orbit Fracture DEFINITION

Back 34

Fracture of one or more of the bones that comprise the orbit
“blowout”: orbit floor fracture

Front 35

Orbit Fracture
•Treatment

Back 35

–Surgical intervention after edema diminishes
–ICE
–HOB elevated-dec pressure, edema, inc drainage
–Nasal decongestants-dec nose blowing
–Steroids-dec inflame

Front 36

avoid what with orbit fracture

Back 36

NO NOSE BLOWING / SNEEZING / vagal stimulation bc inc pressure

Front 37

Mandible Fracture
•Signs / symptoms

Back 37

*Malocclusion

–Gum line lacerations

–Unable to open or close mouth
–Ecchymosis

Front 38

Dental Trauma
Types of dental fractures

Back 38

I-crack in enamel-no pain and sharp break
II-break in denton-cold and heat bother
III-fracture through pulp-painful at rest nerve tissue damaged
IV-damaged in root pain at rest

Front 39

Dental Trauma

treat

Back 39

Re-implantation is possible for 2 hours
Store in saliva, saline, or milk

Front 40

Dental Trauma

If any tooth is unaccounted for ---- is needed

Back 40

CXR

Front 41

Ocular Triage

Back 41

VS
Description of injury
Allergies
Pain

Front 42

Ocular

TX:

Back 42

Irrigate if chemical (alkaline worse)
Immobilizing or protecting an object protruding from globe

Front 43

Ocular Resuscitation

Back 43

Shield eye asap so wont get damage
NO pressure should be applied if globe not intact-cup over it

Front 44

Ocular Assessment

Back 44

Visual acuity-baseline
External features
Pupils-reactive
Anterior segment-bld?
Ocular motility

Diagnosis:
Fluorescein staining-bright green=bad
Intra Occular Pressure-rupture=low
Fundoscopic exam-check retina, blding in back

Front 45

Hyphema

Signs / Symptoms

Back 45

•Pain

•Photophobia
•Blurred vision
•Blood in anterior chamber on exam
•Decreased visual acuity

Front 46

Hyphema

Treatment varies

Back 46

minimal treatment

•Bedrest
•HOB elevation-dec pressure, inc drain
•Eye patch
•Medications
•Beta blockers-topical dec pressure
•Mydriatic agents-dilate promote relax iris
•Steroids-inflam

Front 47

Difintion

Hyphema

Back 47

Blood in the anterior chamber

Front 48

Subconjunctival Hemorrhage
DIFINITION

Back 48

Small blood vessels underneath the conjunctiva ruptures and bleeds

Front 49

Subconjunctival Hemorrhage SIGNS

Back 49

Harmless
Painless, bright red flat patch on sclera
No treatment

assess for cause

Front 50

Periorbital Wounds DIFINITION

Back 50

Injury to eyelids and surrounding periorbital tissue

Front 51

Periorbital Wounds TX look for

Back 51

Look for foreign bodies and globe penetration
Close early

Front 52

Globe Rupture
Penetration of globe
Signs / symptoms

Back 52

*Teardrop pupil

•Deep or shallow anterior chamber
•Altered light perception
•Hyphema
•Vitreous hemorrhage
•Pain with nausea

Front 53

Globe Rupture
Penetration of globe

Diagnosis

Back 53

–History
–Visual acuity
–Flattening of chamber
–Leaking of vitreous humor
–Decreased IOP-tono pen

Front 54

Globe Rupture
Treatment:

Back 54

Avoid eye manipulation and eye drops
Eye shield
Ophthalmology consult
Anti-emetics-prevent inc pressure
Pain/sedation

Front 55

Corneal Abrasion SIGNS

Back 55

Foreign body sensation
Photophobia
Acute onset of pain
Topical anesthesia and
Fluorescein stain and slit lamp exam
Antibiotics
No patching

Front 56

Corneal Laceration signs

Back 56

Present similarly to abrasions
Seidel sign-fluorescein stain on eye bubbling of green

Front 57

Foreign Body difinition

Back 57

Disruption in the integrity of the corneal epithelium

Front 58

Foreign Body
Diagnosis:

Back 58

–Fluorescein and Woods Lamp
–CT scan

Front 59

Foreign Body
Treatment:

Back 59

–Irrigation
–Topical anesthetic
–Topical antibiotics
–Surgery

Front 60

Foreign Body
signs

Back 60

•May be painful
•Decreased visual acuity

Front 61

Chemical Injury which worse acid or akaline

Back 61

Alkaline substances penetrate deeper than acidic substances

Front 62

Chemical Injury tx

Back 62

Irrigate with sterile isotonic saline until tear pH 7.0

Front 63

Remember max trauma

Back 63

•AIRWAY
•BREATHING
•CIRCULATION
•Reassess
•Concurrent injuries are common
•The face is part of the head and head injuries should be considered in most situations
•Facial injuries can be very distracting – stick with ABCs

Front 64

Maxillofacial Assessment

Inspect

Back 64

Inspect
Face symmetry
Look down from eyebrows
Look up from chin
Malocclusion
Evaluate facial nerve

Front 65

Primary Survey Airway Obstruction Treatment

Back 65

 Suction  Open airway  OPA(not if awake)/NPA(no nose if basilar skull fracture)  BVM

Front 66

Le Fort III

Back 66

Separation of midface from skull

pressure on teeth-teeth, nose, eyes move

Front 67

Nasal Fracture signs/symptoms

Back 67

•Swelling, deformity, bleeding, crepitus-air under nose skin

Front 68

Epistaxis Sources:

Back 68

anterior and posterior ethmoid or maxillary arteries