what is the most appropriate initial management for the patient in the photo to the right?

• Periodical Listing
• J Emerg Trauma Daze
• v.9(2); April-Jun 2016
• PMC4843570

J Emerg Trauma Stupor. 2016 Apr-Jun; nine(ii): 73–80.

Management of maxillofacial trauma in emergency: An update of challenges and controversies

Anson Jose

Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, India

Shakil Ahmed Nagori

Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, India

Bhaskar Agarwal

Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, Republic of india

Ongkila Bhutia

Department of Oral and Maxillofacial Surgery, All India Plant of Medical Sciences, New Delhi, India

Ajoy Roychoudhury

Section of Oral and Maxillofacial Surgery, All Republic of india Institute of Medical Sciences, New Delhi, Republic of india

Received 2015 Nov 29; Accepted 2016 Jan 12.

Abstruse

Trauma management has evolved significantly in the by few decades thereby reducing bloodshed in the golden hour. Withal, challenges remain, and one such area is maxillofacial injuries in a polytrauma patient. Astringent injuries to the maxillofacial region can complicate the early on management of a trauma patient owing to the regions proximity to the brain, cervical spine, and airway. The usual techniques of airway breathing and apportionment (ABC) management are often modified or supplemented with other methods in instance of maxillofacial injuries. Such modifications have their ain challenges and pitfalls in an already hard situation.

Keywords: Airway management, bleeding, emergency care, facial injury

INTRODUCTION

Maxillofacial injuries are frequent cause of presentations in an emergency department. Varying from unproblematic, common nasal fractures to gross communition of the face, management of such injuries tin exist extremely challenging. Injuries of this highly vascular zone are complicated by the presence of upper airway and proximity with the cranial and cervical structures that may be concomitantly involved. While, with non maxillofacial injuries, a protocol for direction of airway, breathing, and circulation is relatively well established; injuries to this region accept often been a field of study for discussion. We nowadays an overview of the initial management of such patients in terms of airway, cervical spine, and apportionment. The challenges and controversies in the management of such patients are discussed.

AIRWAY

The start and foremost maxillofacial injuries are usually complicated by a compromised airway. On account of its location in the "crumple zone" of the face, even minor injuries tin can result in significant prey to the airway. The state of affairs may be aggravated by macerated consciousness, alcohol, and/or drug intoxication, equally well as contradistinct laryngeal and pharyngeal reflexes, making the patient vulnerable to the take chances of aspiration. Furthermore, this scenario is complicated by the presence of broken teeth, dentures, foreign bodies, avulsed tissues, multiple mandibular fractures, and massive edema of glottis which can cause a direct threat to the airway. Alcohol, drugs, and caput injury forth with ingested and pooled blood can trigger nausea and vomiting. The act of vomiting prompts a rise in intracranial tension which in turn increases the bleeding and salivation that occludes the airway. Vomiting and hazard of aspiration are particularly high when patients are in supine position. Technically speaking, in patients with multiple facial fractures, the deportation of maxilla or mandible posteriorly can decrease the airway patency[ane] [Figures ​ 1 and ​ 2]. Although of less frequency, injuries to larynx and trachea tin can likewise create airway embarrassment.

Posteriorly displaced bilateral parasymphyseal mandibular fracture can complicate the airway

Airway in severely communited midface fracture can exist challenging to manage

Direction

Despite recent major medical advancements, the basic key of airway management remain the same. Upper airway obstruction due to craniomaxillofacial trauma invariably results in a threatened airway. The potential concomitant injury to other organs and the presence of an unclear C-spine further complicates airway management. A variety of airway handling techniques are currently available. However, aught is a fool proof and should be tailored co-ordinate to a particular situation depends on the magnitude and type of the injury. Supervision of an emergency situation similar this demands the experience and technical skills of the emergency operator and he or she should always prognosticate airway obstruction and exist qualified enough to perform a surgical airway.

Initial cess

The strategy of look, listen, and feel helps to figure out airway obstruction and anticipated airway complications.[two] The airway direction approach, especially in unconscious trauma patients should be complimented with the protection of C-spine. In high-velocity trauma which involves the mandible, swallowing mechanism is altered due to pain and ineffective protective reflex modulation, results in difficulty to go along the airway clear.[3] Hence, it is important to protect the airway from blood and vomitus to prevent aspiration and farther pulmonary complications. The palpation of trachea reveals any collapse or deviation. Larynx should exist auscultated for stridor. The presence of any tracheal tug or laryngeal stridor explains an impending threat to the airway. The "difficult intubation" tray should be accessible all times with consummate equipment to deal with, namely tracheal tube introducer, supraglottic airway devices, combitubes, endotracheal tubes, tracheostomy fix, and craniotomy kit.[4] When management by conventional definitive airway is less likely, it is prudent to accept an experienced team at hand for establishing rescue surgical airway.

Strictly speaking, irrespective of the injury, maxillofacial trauma patients should exist given acceptable oxygenation with uninterrupted saturation monitoring. The spinal collars should be applied with extreme caution to prevent any inadvertent posterior displacement of mandible thus complicating airway. Contrary to other polytrauma, the airway of maxillofacial patient is at constant risk. Hence, the strategy is a systematic analysis of the airway as delayed airway compromise may occur due to the displacement of tissue, bleeding, and swelling.[2] High-volume suction should be available to clear the mouth and oropharynx from blood and secretions.[five] Nevertheless, care should be taken not to irritate the oropharynx with suctioning as it predisposes the patient to airsickness. In addition, conscientious monitoring of patient at this instant shall provide an thought most the response of protective reflexes such as gagging and swallowing. Oropharyngeal guedel can be used effectively, one time airway is articulate. However, the placement of guedel itself induces retching, laryngospasm, and often displaces the tongue posteriorly thereby further aggravating airway. In the absence of any protective reflex, emergency endotracheal intubation is the rule. In patients with a patent airway and absent-minded spontaneous animate, bag-mask ventilation is the procedure of choice. A tightly fitted mask with concurrent jaw thrust is often plenty to maintain ventilation. Nonetheless, obese patients and patients with beard possess problems thus reducing the effectiveness of ventilation. Preferably, mask ventilation in trauma patients should be a "2-person technique," one holding the mask tightly fitted to oral fissure and the other operating the purse. Similarly, adjunctive airway maneuvers such every bit mentum lift and jaw thrust should be performed with intendance. Head tilt and "sniffing the morning time air" positions are absolute contraindications in case of suspected C-spine injury. In patients with suspected C-spine injury, the direction protocol is to keep the patient supine to further reduce C-spine morbidity likewise as immobilizing the cervical spine using hard cervical collars. Such collars may reduce visibility to the oropharynx that may exist of considerable important. Unfortunately in this scheme, the question to be answered is how finer a trauma team can intubate the patient? On this account, a study reveals that trauma patients present with noisy or chock-full airways. The unsuccessful intubation rate is an alarming 12%.[half-dozen] While in a study past Martin et al.,[7] out of 3423 emergent intubations performed, ten.iii% required multiple attempts and were classified as "difficult."

Definitive airway

The concept of the definitive airway is maxillofacial trauma is probably much more important every bit compared to trauma to other body parts. The primary indications are given in Table 1. Conventional straightforward definitive airway options are orotracheal intubation, nasotracheal intubation, and surgical airway. Orotracheal intubation with the aid of laryngoscope is the about feasible and safest method of pick. However, if the C-spine is not articulate, it is prudent to perform manual axial in-line stabilization during orotracheal intubation. Although evidence in literature imparts that some cervical motility is inevitable,[8,9] orotracheal intubation is comparatively safe in an unclear cervical spine. It is easier to perform, quick and causes minimal mobilization of the cervical spine in skilled easily.[10] In astringent avulsive facial injury or in laryngeal or tracheal plummet, placement of orotracheal tube is challenging, and surgical airway is the choice. Nasotracheal intubation is another effective culling and can be achieved in patients without communited midface or skull base injury. This is of particular importance in managing airway obstruction due to lower face injury and suitable for patients in which the mouth opening is inadequate. The methods are of two types either blind or fiberoptic assisted. The traditional blind technique by a trained professional is quick, effective and does non need premedication. The enthusiasm toward fiberoptic technique, on the other paw, is limited by the presence of copious secretions or blood in the airway, technique sensitivity, and increased time required. Similarly, laryngeal mask airway (LMA) and combitube, although not a definitive one, are alternatives to a failed or difficult intubation. These devices purchase time by bridging the airway until a definitive airway is achieved. However, it does not protect the airway from regurgitation and aspiration. Little expertise required and piece of cake placement permit the combitube to exist used blindly in emergency or in prehospital settings. However, its utilize in patients with altered anatomy as in complex maxillofacial trauma may crusade injury to the trachea, larynx, and esophagus when not properly placed.[11] Although suggested, retrograde intubation through cricothyroid puncture is very fourth dimension-consuming and required expertise. Hence, it is of limited use in emergency.[12] During airway maintenance technique, the manipulation of cervical spine should exist kept minimal and whatever method you follow, always retrieve the dictum "to do no further harm."

Table one

Indications for definitive airway

When noninvasive techniques for securing airway fail, the surgical airway is the only available pick. They are of two types: Cricothyroidotomy and tracheostomy.[xiii] The cricothyrotomy is the most convenient method in emergency and tin be performed by needle (needle cricothyrotomy) or by surgical scalpel (surgical cricothyrotomy).[14] Although some schools advocates needle cricothyrotomy, its standard use is debatable. The failure rates and insufficient oxygenation precludes it utilize, and surgical cricothyroidotomy is the pertinent method of choice in emergency. Tracheostomy in most of the cases is performed as an constituent procedure, once the patient is stabilized by cricothyrotomy. Despite percutaneous tracheostomy claims to reduce the operative fourth dimension and surgical risks in good hands, its routine use is non indicated in emergency.

Protocol for airway management in maxillofacial trauma[ii]

• Anticipate and recognize an airway obstacle

• Clear the airway, position the patient. Perform chin lift and jaw thrust maneuver

• Ostend the nasal and oral aperture are clear then utilize artificial airways and

• Perform bag-valve-mask ventilation. Preferably "2-person technique"

• Oroendotracheal intubation

• In unsuccessful orotracheal intubation or "cannot ventilate cannot intubate situation" perform surgical airway [Figure 3].

  

  Direction of airway in maxillofacial trauma

Controversies and pitfalls

In the direction of airway, the virtually of import perspective is to facilitate a patent airway and protect the airway from saliva, blood, and total tum. It varies from the uncomplicated tactic of patient positioning to circuitous surgical procedures depend on the caste of injury and propensity of anticipated airway obstacle. The effectiveness of the jaw thrust maneuver in multiple fractures, particularly in communited mandible fracture is debatable. Apart from having just a finite potential to enhance the airway, the traction movements employed in this method further increases the likelihood of bleeding and associated harm. Likewise, bag-mask ventilation is potentially chancy, especially in Le Fort II, III, and nasoethmoidal fracture with suspected fracture of the anterior cranial fossa. Mechanical ventilation to maintain the oxygen saturation carries the risk of forcing infectious material into a basilar skull fracture and displacing nasal droppings and foreign particles into the encephalon. The fear of tension pneumocephalus particularly when there is a tear in dura, by this route of ventilation, is not well known among emergency clinicians.[fifteen,16,17,18] This is a life-threatening condition and can crusade rapid deterioration of Glasgow Coma score (GCS) and late neurological problems.[eighteen] Although endotracheal intubation is the gilded standard definitive airway, one of its potential drawbacks is difficulty in assessment of GCS. Extensive edema of the glottis and retropharyngeal hematoma from fractured spine complicated the apply of orotracheal intubation. The nasotracheal intubation is generally contraindicated in patients with communited midface fracture due to the fear of iatrogenic penetration of tube via fracture of associated skull base.[eleven] In a study by Rosen et al.[19] on 82 patients with midface fractures, no incidence of such tube penetration was noted. The authors noted that this potential complexity is a matter of concern merely in central inductive skull base fractures. Similarly, just three cases of iatrogenic intracranial displacement have been reported in literature.[20,21,22] Thus, nasotracheal intubation in not an absolute contraindication in maxillofacial trauma; in fact, it may exist the preferred mode of intubation in conscious patients since this demand non require cervix manipulation or premedication for sedation and muscle relaxation. Failure to perform endotracheal intubation necessitates the use of supraglottic devices (LMA) until a definitive airway is maintained. These devices practise non seem to forestall aspiration and are likely to exaggerate gagging, airway resistance, and oropharyngeal decubitus outcome.[23] A patient with laryngeal injury is also an absolute contraindication for LMA. Cricothyrotomy on the other hand, having an airway apparatus that is adjacent to a surgical field could possibly cause wound contamination and cut down access while definitive repair of maxillofacial trauma is carried out past an extra oral route.

A meta-analysis past Hubble et al.[24] has shown that the success rate of needle cricothyrotomy is 65.viii% and surgical cricothyrotomy is 90.5% when performed in emergency. Despite the popularity of percutaneous tracheostomy in the last few years, there is no scientific testify that the airtight technique is superior or easier than the standard tracheostomy in emergency.[25,26] A semi-open tracheostomy is an innovational alternative in patients with C-spine injury and nonpalpable trachea. This is accomplished past performing a 2–3 cm skin incision to expose the pretracheal fascia and subsequently past a percutaneous method.

CERVICAL SPINE AND MAXILLOFACIAL TRAUMA

In a circuitous maxillofacial trauma scenario, cervical spine fracture should always exist considered unless proven otherwise. The incidence is very less and ranges from 1% to ten% in all maxillofacial trauma.[27,28,29,xxx,31,32] Because of the proximity of cervical spine whatsoever force of such magnitude that causes facial fractures can potentially traumatize the c-spine and its ligamentous attachments.

The clearance of cervical spine consequent to an injury is an area of much argue and discussion.[33,34,35,36] Clinical awareness most the status of cervical spine is achieved using the most commonly used three show-based decision protocols, namely Nexus criteria,[37] Canadian spine dominion,[38] and Harborview criteria.[39] In patients who are awake, clearance protocol can exist finer implemented by a detailed clinical examination; however, in an unconscious patient, it is non possible. The clearance of such patients hinges on clinical test, hazard, and radiographic examination such as noncontrast computerized tomography,[xl] static flexon extension radiography,[41] magnetic resonance imaging,[42] and dynamic fluoroscopy.[43] By and large, without the adjunct of radiographic survey, the patient can exist excluded from spine injury if they display the post-obit:[37]

• Patient with perfect neurological condition. (normal GCS)

• Not under the effect of drugs (booze, others)

• Absence of pain/tenderness in posterior midline of cervical spine

• Devoid of distracting, painful impairments.

Nonetheless, at that place is a continuing debate about the credibility of these clinical protocols in C-spine without the help of radiographic cess. In a neurologically unstable patient, the cervical spine must be immobilized irrespective of the injury. The universally accepted method of C-spine direction includes hard collars, block and straps, and manual axial inline stabilization. These management methods are rather emotional and lack adequate scientific basis, especially in conscious patients.[36] However, the mostly accepted fact is that the application of collar protects and stabilizes the cervical spine temporarily until definitive management is done. The cervical collar should be practical by an experienced person or a person trained to do that. It should be snugly fitted to aid immobilization and while applying care should exist taken not to shrink the neck. Improper applications of collars are implicated in airway obstruction and perhaps rise in intracranial pressure past affecting the venous return from the encephalon.[44,45] This complicates head injury and increases the cerebrospinal fluid leakage form skull base fractures and creates issues during operative repair of maxillofacial injuries.

The misconception trailing spinal immobilization post-obit trauma described past Benger et al.[46] is as follows:

• Injury to cervical spine is a potential complication in trauma patients

• Additional move of cervical spine after trauma causes supplementary impairment to C-spine

• The wearing of cervical collars helps in immobilization and stabilizes C-spine

• Equally a safety measure, it can exist applied to all patients since it is "harmless."

Trauma patient may have an unstable spine injury. Even so, the incidence is depression (1.7%), of which only 0.ane% shows pregnant neurological issues.[38] Hauswald et al.[33] constitute no disarming differences in neurological events in a study comparing two countries, in which one follows strict spinal immobilization and one not in 454 patients. It can conclude that in trauma the initial touch may cause spinal injury, however, careful movement or treatment the neck is unlikely to cause further harm. In add-on, even in case of undiagnosed injury, that muscle splinting and pain is the best restraint and is excellent or superior to any externally practical devices. Conscious patients find an appropriate stable position which is near befitting for their particular blazon of injury.[46] Awarding of cervical collar is logical in patients those who are incapable of protecting their spine equally in an unconscious patient or patient under the leverage of drugs. It is also sensible when the general status of the patient is failing, or the management of patient requires sedation and anesthesia. Nevertheless, a perfectly applied neckband past trained personnel allows a minimum xxx° of flexion/extension/rotation motility of the neck.[34] Ben-Galim et al.[47] has shown there is an average seven.3 mm of hyperextension between C₁ and C₂ while wearing a neckband. Another cadaveric study quoted that significant amount of movement occurs to C-spine while placing and removing of collars.[48] If it is so, studies have proved that a sandbag will offer ameliorate protection and immobilization than a rigid collar.[35] Furthermore, the cervical collar has been associated with a number of disadvantages that include reduced admission for orotracheal intubation, central venous access, increased intracranial pressure, and bug with surgical direction of maxillofacial trauma.[49,l] Thus, collar nosotros use in the emergency department or prehospital setting may neither provide any benefit nor protection against secondary injuries. At that place is no scientific evidence for that. Nonetheless, the practice of using a cervical collar is recommended by us taking into account of the fact that all emergency departments and prehospital weather condition may non exist optimally equipped ideal for a conscientious and convenient transit.

Apportionment AND HEMORRAGHE Control

After the acquisition of airway and addressing breathing problems, attention must be given to apportionment. Maxillofacial injuries are very decumbent to massive hemorrhages, and life-threatening hemorrhage tin can vary from 1.4% to 11%.[51,52,53,54,55] One out of every x complicated facial fractures bleeds significantly. The chief vessels involved are an ethmoid avenue, ophthalmic, vidian branch of internal carotid, and maxillary artery.[54,56,57] In virtually cases, bleeding can exist are hands controlled, but rarely severe epistasis that ranges from ii% to 4%[55] of all facial trauma arises from the maxillary artery, creating difficulty in hemorrhage control. It is of import to differentiate bleeding from the skull base of operations fracture and oral bleeds by careful ascertainment of throat for lacerations and tears. Patients with multiple maxillofacial injuries must exist taken care. Otherwise, they will become into hemorrhagic daze fifty-fifty though merely 1.iv%[51] such cases take been reported. In the supine position, bleeding into oropharynx and swallowed blood in a conscious patient may cause vomiting thus, risking the C-spine.[58] Hence, the purpose of hemostasis in maxillofacial trauma patient, is two-fold, namely to protect the airway, and to reduce blood loss.

Control of hemorrhage tin can exist accomplished by force per unit area packing, manual reduction of fractures,[54] balloon tamponade,[59] and in severe cases with angiography followed past trans-arterial embolization[lx,61,62,63] or in some cases with direct external carotid artery (ECA) ligation[64] [Figure iv]. Severe nasal bleeding may go along even after acceptable inductive and posterior nasal packing [Figure v]. Sakamoto et al.[sixty] institute that Foley's catheter balloon tamponade and ECA ligation does not respond in 72.2% of epistaxis. Balloon tamponade should be used with circumspection in communited midface fracture since it may crusade displacement of fractured fragment into orbits and brain.[59,65] The effectiveness of surgical exploration and ECA ligation particularly in cases of nasoorbital ethmoidal fracture are proven ineffective due to superfluent collaterals from the internal carotid artery at this region.[66] In uncontrolled bleeding that does non respond to noninvasive methods, angiography and selective embolization of bleeder is the method of choice. However, the use of trans-arterial embolization in managing epistaxis is not favored past many authors except in firearm injuries on the surface area of anastomoses of external and internal carotid system.[54] Yet, these anastomoses accept an increased adventure of passage of embolic material into the encephalon causing serious neurological issues. The complications of selective embolization take been reported in 50% population, which includes seventh nerve palsy, trismus, necrosis of tongue, blindness, migration of emboli into internal carotid, and somewhen a stroke.[67] One time bleeding is controlled maxillofacial injuries non always require early correction. Ii large diameter IV lines should exist placed for replacing fluid loss; similarly, exclude other concealed bleeding from the thorax, abdomen, and vascular injury of other vital organs.[68] Coagulopathy if whatever should be corrected. Temporary stabilization of patient allows for whatever farther resuscitation, clinical and radiographic investigations, and definitive intendance.

Management of bleeding in maxillofacial trauma

Anterior and posterior nasal packing is usually the offset selection for severe maxillofacial bleeding

Decision

The gravity of all maxillofacial injuries lies in the fact that they pose an immediate threat to life equally a result of its proximity to both the airway and brain. However, each case is unique; thus, the management is exacting even for the most experienced of professionals. In any given scenario no treatment approach can be described every bit being sure and flawless. The need of the hour is a multipronged approach requiring a partnership between several departments. While new engineering science and material developments have helped ease the situation, it is the timely intervention, sheer skill, and presence of mind of emergency personnel, and surgeons that counts.

Announcement of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/accept given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not exist published and due efforts volition be fabricated to conceal their identity, just anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

In that location are no conflicts of involvement.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843570/

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