Maxillofacial, Ophthalmic

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Maxillofacial, Ophthalmic Dental Trauma

• EMS Professions
• Temple College

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Morbidity Mortality

• Mortality
• Primarily associated with brain and spine injury
• Severe Facial fractures may interfere with airway
  and breathing
• Morbidity
• Disability concerns
• Cosmetic concerns

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Maxillofacial Trauma

• Causes
• MVC, home accidents, athletic injuries, animal
  bites, violence, industrial accidents
• Soft tissue
• lacerations, abrasions, avulsions
• vascular area supplied by internal and external
  carotids

• Management -
• Seldom life-threatening unless in the airway
• consider spinal precautions
• have suction available and in control of
  conscious patients
• control bleeding

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Anatomy Physiology Review

• Arteries
• temporal artery
• mandibular artery
• maxillary artery
• Nerves
• trigeminal (cranial nerve V)
• facial (cranial nerve VII)

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Anatomy Physiology Review

• Bones
• nasal
• zygoma / zygomatic arch
• maxilla
• mandible

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Facial Fractures

• Fx to the mandible, maxilla, nasal bones, zygoma
  rarely the frontal bone
• S/S -
• pain, swelling, deep lacerations, limited ocular
  movement, facial asymmetry, crepitus, deviated
  nasal septum, bleeding, depression on palpation,
  malocclusion, blurred vision, diplopia, broken or
  missing teeth

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Facial Fractures

• Mandibular Fx -
• numbness, inability to open or close the mouth,
  excessive salivation, malocclusion
• Anterior dislocation
• may be caused by extensive dental work, yawning
• Condylar heads move forward and muscles spasm

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LeFort Fractures

• Specially named facial fractures
• Usually requires significant forces especially
  for LeFort II and III
• LeFort I - Maxillary fracture with
  free-floating maxilla
• LeFort II - Maxilla, zygoma, floor of orbit and
  nose
• LeFort III - Lower 2/3 of the face

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LeFort Fractures
I II III
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Signs and Symptoms

• Often associated with orbital fractures
• risk of serious airway compromise (bleeding
  edema)
• contraindication to NG tube or nasotracheal
  intubation
• Present with
• Edema, Epistaxis, Numb upper teeth
• Unstable maxilla, CSF rhinorrhea
• Unusual facial appearance
• donkey face (lengthening)
• pumpkin face (edema)
• nasal flattening

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Management

• Spinal motion restriction
• Airway is the most difficult and most critical
  priority
• Consider Early Intubation
• Surgical Airway may be the only alternative but
  NEVER the first consideration
• Suction Control Bleeding
• Critical trauma patient - Transport accordingly

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Facial Fractures

• Caution
• NG tube or Endotracheal tube placement may be
  HAZARDOUS!!!

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Ear Trauma

• External injuries
• lacerations, avulsions, amputations, frostbite
• Control bleeding with direct pressure
• Internal injuries
• Spontaneous rupture of eardrum will usually heal
  spontaneously
• penetrating objects should be stabilized, not
  removed!
• Removal may cause deafness or facial paralysis
• Hearing loss may be result of otic nerve damage
  in basilar skull fracture

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Anatomy Physiology Review

• Ear
• Outer Ear (Pinna)
• Cartilage
• little blood supply
• External Ear canal
• mucous membrane that secretes wax for protection
• Middle Ear
• separated from external canal by ear drum
• delicate structure needed for hearing

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Ear Injuries

• Separation of ear cartilage
• treat as an avulsion
• dress and bandage
• consider disability and cosmetic concerns
• Bleeding from ear canal
• cover with loose dressing only

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Barotitis

• Changes in pressure cause pressure buildup and/or
  rupture of tympanic membrane
• Boyles Law, at constant temperature, the volume
  of gas is inversely proportionate to the pressure
• s/s - pain, blocked feeling in ears, severe pain
• equalize pressure by yawning, chewing, moving
  mandible, swallowing (open Eustachian tubes
  allowing gas to release)

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Eye Anatomy

• Bony orbit
• Eyelid
• Lacrimal apparatus
• Sclera
• Cornea
• Conjunctiva
• Iris
• Pupil
• Lens
• Retina
• Optic nerve

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Eye Injuries

• Penetrating
• Abrasions
• Foreign bodies (deep, superficial, impaled)
• Lacerations (deep or superficial, eyelid)
• Burns
• flash
• acid/alkali

• Blunt
• Swelling
• Conjunctival hemorrhage
• Hyphema
• Ruptured globe
• Blow-out fracture of orbit
• Retinal detachment

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Blow-out Orbital Fracture

• Usually result of a direct blow to the eye
• S/S - flatness, numbness
• epistaxis, altered vision
• periorbital swelling
• diplopia
• inophthalmos
• impaired ocularmovement

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Foreign Bodies

• S/S - sensation of something in eye, excessive
  tearing, burning
• Inspect inner surface of upper lid as well as
  sclera
• Flush with copious normal saline away from
  opposite eye

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Corneal Abrasion

• Caused by foreign body objects, eye rubbing,
  contact lenses
• S/S - pain, feeling of something in eye,
  photophobia, tearing, decreased visual acuity
• irrigate, patch both eyes
• Usually heals in 24 to 48 hours if not infected
  or toxic from antibiotics

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Other Globe Injuries

• Contusion, laceration, hyphema, globe or scleral
  rupture
• S/S - Loss of visual acuity, blood in anterior
  chamber, dilation or constriction of pupil, pain,
  soft eye, pupil irregularity

• Management
• Consider C-spine precautions due to forces
  required for injury
• No pressure to globe for dressing, cover both
  eyes
• Avoid activities that increase intra-ocular
  pressure

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Mouth Injuries

• Usually result from
• MVCs
• Blunt injury to the mouth or chin
• Penetrating injury due to GSW, lacerations, or
  punctures

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Anatomy Physiology Review

• Muscles
• Tongue
• Masseter muscles
• Nerves
• Hypoglossal
• Glossopharyngeal
• Trigeminal
• Facial

• Bones
• Mandible
• Maxilla
• Hyoid
• Palate
• Teeth

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Mouth Injuries

• Primary concerns
• Airway compromise secondary to bleeding
• FBAO secondary to broken or avulsed teeth
• Impaled object
• Management
• ABCs
• Suction prn
• Stabilize impaled object
• Collect tissue tongue or tooth

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Dental Trauma

• lt 15 minutes, may be asked to replace the tooth
  in socket
• do not rinse or scrub (removes periodontal
  membrane and ligament)
• preserve in fresh whole milk
• Saline OK for less than 1 hour

• 32 teeth in normal adult
• Associated with facial fractures
• May aspirate broken tooth
• Avulsed teeth can be replaced so find them!
• Early hospital notification to find dentist

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Nasal Injuries

• Variety of mechanisms including blunt or
  penetrating trauma
• Most common injury
• Adults - Epistaxis
• Children - Foreign bodies

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Anatomy Physiology Review

• Nasal bone
• between the eyes
• Nasal cartilage
• provides shape to nose
• Internal
• septum
• turbinates
• sinuses

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Nasal Injuries

• Epistaxis
• anterior bleeding from septum
• usually venous
• posterior bleeding
• often drains to airway
• may be associated with
• sphenoid and/or ethmoid fractures
• basilar skull fracture

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Nasal Injuries
Often looks worse than it is! A little patience
and direct pressure work wonders!
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Nasal Injuries

• Foreign Bodies
• Variety of objects
• food
• toys
• Often can be left alone and removed later

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Nasal Injury Management

• Epistaxis
• Direct pressure over septum
• Upright position, leaning forward or in lateral
  recumbent position
• If CSF present, do not apply direct pressure
• allow to drain

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Neck Trauma

• Neck - 3 zones
• 1 sternal notch to top of clavicles (highest
  mortality)
• 2 clavicles or cricoid cartilage to angle of
  the mandible (contains major vasculature and
  airway)
• 3 above angle of mandible (distal carotid,
  salivary, pharynx)

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Neck Trauma

• Transected Trachea
• Larynx separated from trachea or fractured
• vocal cord swelling
• altered airway landmarks
• soft tissue edema
• Vessel lacerated or torn
• severe bleeding (large vessels)
• airway compromise
• risk of air emboli, hypoxia, or ischemia

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Neck Trauma

• Signs Symptoms
• pale or cyanotic face
• obvious external injury
• frothy blood or sputum from wound
• SQ air
• voice change
• feeling of fullness in throat
• Signs of stroke with air emboli

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Esophageal Injury

• Especially common in penetrating trauma
• S/S may include subcutaneous emphysema
• neck hematoma, blood in the NG tube or posterior
  nasopharynx
• high mortality rate from mediastinal infection
  secondary to gastric reflux through the
  perforation
• Consider Semi-fowlers vs. supine position unless
  contraindicated by MOI.

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Neck Trauma Management

• ABCs
• Suction
• Intubate EARLY!!!
• May require cricothyrotomy
• stop bleeding as best as possible
• Occlude large blood vessel quickly
• Left lateral position with occlusive dressing to
  wound
• Consider spinal motion restriction
• Stabilize impaled objects
• Transport to trauma center

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Cranial Nerve Hints

• May not be helpful in unconscious patients, but
  if they happen to wake up
• Cranial nerve I - loss of smell, taste (basilar
  skull fracture hallmark)
• Cranial nerve II - blindness, visual defects
• Cranial nerve III - Ipsilateral, dilated fixed
  pupil
• Cranial nerve VII - immediate or delayed facial
  paralysis (basilar skull or LeFort)
• Cranial nerve VIII - deafness (basilar skull fx)