Acute injury, particularly to maxillofacial region

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Information about Acute injury, particularly to maxillofacial region
Science-Technology

Published on April 6, 2014

Author: kanodiarakesh1

Source: authorstream.com

Competence in Physical assessment of patients of surgery and evaluation of patients presenting with acute injury, particularly to maxillofacial region : Competence in Physical assessment of patients of surgery and evaluation of patients presenting with acute injury, particularly to maxillofacial region Initial Patient Contact : Initial Patient Contact Integration and coordination of the initial resuscitation of the acutely injured patient commonly begins in a hospital emergency facility by providers trained to diagnose and treat life threatening wounds. Facial trauma injuries are usually not life threatening and do not require emergent treatment. Patients are assessed and their treatment priorities established based on their injuries, their vital signs, the injury mechanism, and their age. PowerPoint Presentation:  The early management and treatment planning of the maxillofacial trauma patient begin with the initial greeting of the patient and end when the trauma victim has achieved maximum surgical, functional, psychosocial, and financial benefits, Evaluating the patient and creating a plan to accomplish objectives important to the care of the total patient begin with the initial history and physical examination. THE ABCDE'S OF TRAUMA CARE: THE ABCDE'S OF TRAUMA CARE The maxillofacial surgeon has a role to play in the context of the ABCDE'S of trauma care. Airway Maintenance With Cervical Spine Protection Removing fractured teeth, denture fragments, unsecured and unsalvageable bone fragments. Facilitating endotracheal intubations by repositioning facial fracture segments to open the oral and nasopharyngeal airway. Breathing and Ventilation Temporarily stablizing the posteriorly positioned fractured lower jaw with bilateral condyle and symphysis fractures that are obstructing the airway in a conscious patient. Circulation With Hemorrhage Control : Circulation With Hemorrhage Control Packing the aggressively hemorrhaging nose or intraoral wound to both improve airway and control bleeding. Clamping and tying obvious and clearly accessible large, hemorrhaging facial vessels and scalp bleeders. Placing a pressure bandage to control bleeding from extensive facial lacerations and / or scalp bleeding. Disability : Neurologic Status : Disability : Neurologic Status Neurologic status establishes the level of consciousness, pupil size, and reaction Periorbital trauma may cause direct or indirect ocular injuries that may alter pupillary size, contour, and response that may confound the neurologic examination in a patient with an intact central nervous system. Establishing the peripheral nature of the pupillary changes in patients with sensorium changes (alcohol, drugs) unrelated to intracranial trauma PowerPoint Presentation: Exposure / environmental Control Removing dentures, tongue, and facial rings Removing eye contacts Secondary Survey of Patient Diagnosis and treatment planning of the facial trauma victim are part of the head-to-toe evaluation of the injured patient. Special procedures, such as radiologic evaluations and laboratory studies, are obtained at this time. Ample The AMPLE mnemonic routinely applied to the trauma patient is also useful when evaluating facial trauma. PowerPoint Presentation: Allergies Establishing allergies to frequently prescribed medications, such as antibiotics and pain medications. Medications Currently Used Side effects and toxic reactions from medications may have been the cause of the patient's accidental fall. Drug abuse history may complicate pain management Medications the interfere with bleeding and clotting mechanisms. e.g. anticoagulants, Aspirin etc. PowerPoint Presentation: Past illnesses/ Pregnancy Previous or recent facial trauma Cardiovascular and pulmonary conditions that are grave enough to cause anesthesia concerns or that portend a high surgical risk, especially in the elderly. illnesses that are associated with delayed healing and / or contribute to a higher risk of infection Organ transplant patients Immunosuppressive illnesses PowerPoint Presentation: LAST MEAL Urgent surgical intervention of injuries within hours of the traumatic event may be indicated when airway and / or bleeding problems are problematic or facial injuries require early care Careful coordination with anesthesia to reduce vomiting and aspiration. PowerPoint Presentation: History of Present illness, Chief Complaint and Physical Examination Accurate subjective data gathering depends on a completely lucid, truthful patient providing factual information that will be consistent with the physical examination findings. Patients with intracranial injuries, a alcohol – or drug related sensorium disturbances, or a preaccident debilitated cognitive condition could deprive the examiner of all or a part of the valuable historical findings. Upper face and skull injureis Upper face and skull injuries should be suspect when the victim reports headache, nasal stuffiness, Ioss of consciousness, and forehead numbness. PowerPoint Presentation: MIDFACE INJURIES Visual acuity changes, diplopia, change in occlusion trisums, paranasal and infraorbital numbness, airway obstruction are consistent with midface injuries. PowerPoint Presentation: LOWER FACE INJURIES Changes in occlusion, jaw pain, lower lip numbness, preauricular pain, ear stuffiness, and trismus are characteristic of mandible fractures. At the least, all patients who have sustained maxillofacial trauma should receive a comprehensive focused head, face, and neck examination by the maxillofacial surgeon. In additional, the maxillofacial surgeon should be aware of other organ system findings by personally examining systems beyond the face or by being very familiar with the findings of other caregivers. The maxillofacial surgeon must know the neurologic status of his facial trauma patient, the pulmonary and cardiovascular health of the patient as a candidate for anesthetic, his hematologic condition and fluid and electrolyte stability. General Patient Status Inspection : General Patient Status Inspection Reassess the ABCDE's and intervene if the patient's status has changed either negatively or positively. For example, a previously well-ventilated patient may have increased facial and pharyngeal edema that now is interfering with respirations. Further airway management may be indicated before proceeding with the physical examination. Cervical spine status must be established and the spine protected from harmful movements. The cervical spine must be stabilized when the accident events suggest the possibility of cervical or lower spine injury. PowerPoint Presentation: A lateral, cross table cervical spine x-ray should be obtained and reviewed as early as possible. The spine cannot be definitively cleared without a survey of the patient's subjective spine complaints. Observe the patient's general demeanor, alertness, and affect. Look for signs of poor chest excursions, paradoxical breathing, and changes in neurologic status. Review vital signs including temperature. Establish signs of compromised cardiovascular performance (declining blood pressure, increased pulse rate, pallor, clammy skin, poor nail bed capillary refilling, and neck vein distention). Look for movement of the extremities and the patient's ability to localize pain. PowerPoint Presentation: NEUROLOGIC Assess the patient's level of consciousness using the mnemonic OMIT. Orientation Impaired consciousness is almost without exception the earliest clinical finding in a trauma victim with a closed head injury. A patient may be considered "conscious" when he or she is awake – oriented to time place, and person – and able to recall recent events. Memory Patients should be asked to recall recent events. Confronting the victim's recent memory ability 10 to 15 minutes after giving the patient real or contrived information may establish that the patient is not fully "conscious" Intelligence : Intelligence Establishing the intelligence of an individual is an unexacting science under the best of nontrauma circumstances. Cultural, racial, and socio-economic biases can easily skew the results of impre-cise intelligence measuring tools that have little significance in the examiantion of the acutely injured patient. Delayed secondary neurologic studies may uncover subtle memory changes following head trauma. In the acute setting, assuming the patient is conscious enough to respond verbally, simply asking the patient to start from 100 and subtract a series of 7's can be useful. Talk : Talk Talking is a sensory and motor skill that depends on the person's ability to receive information intracranially, and then to cerebrally accurately process that information. Patients may not be able to talk or have difficulty communicating verbally when anterior cervical trauma causes laryngeal injury or when the recurrent laryngeal nerve is injured high up in the chest. Respiration : Respiration Central nervous system, upper airway, or lower airway injury can cause poor respiratory health either as an isolated wounding of an anatomic site or as the result of multiple site dysfunction. For the purposes of presentation, the cause of inadequate breathing is described by anatomic site and organ system. In practice all the organ systems contributing to respiratory function are examined concurrently in the initial trauma survey and individually after severe, life-threatening breathing conditions are identified and managed. Extraocular muscle movements : Extraocular muscle movements In the cooperative, conscious patient, diplopia and signs of extraocular muscle (EOM) entrapment are indicators of orbital wall fracture or cranial nerve injury (lateral rectus abducens, superior oblique trochlear, remaining extra ocular muscles oculomotor. Pupils Pupils should be equal, round, and reactive to light and accommodation (PERRLA). MOTOR CONTROL : MOTOR CONTROL Observing the patient's ability to obey commands, localize pain, and withdraw his or her extremities appropriately to demonstrate normal flexion can easily and quickly be established in most patients. Lateraliz­ing signs, such as inappropriate extremity movements, abnormal flexion (decorticate) or extension (decere­brate), or no movements (flaccid) are findings of pro­gressive involvement of lower centers of the brain with impending brainstem herniation CRANIAL NERVES : CRANIAL NERVES A rapid survey of the cranial nerves can provide the examiner with normal and abnormal findings that point to facial and intracranial injuries. Loss of smell and changes in light perception and pupil reactivity are indicators of craniofacial base fractures involving cranial nerves I, II, and III. Disconjugate eye move­ments may be caused by injuries to cranial nerves III, IV; and VI. PowerPoint Presentation: Testing the five branches of the facial nerve and finding paralysis of all or of individual branches may be caused by cranial base fractures including the petrous portion of the temporal bone. Parotid area lacerations often involve distal branches of the facial nerve. The peripheral level of facial nerve injury must be established and more proximal injuries repaired. CRANIAL NERVES: CRANIAL NERVES Otorrhea may be accompanied by hearing loss and possible injury to cranial nerve VIII. Loss of fore-head, midface, and/or lower lip sensation is a strong indicator of facial bone fractures. Loss of sen­sation in the infraorbital region in a patient who has received a concentrated blow to the eye is strongly suggestive of an orbital floor blowout fracture. PowerPoint Presentation: Con­versely, it would be extremely rare to have a notable orbital floor fracture without injury to the infraorbital nerve. Cranial nerves IX, X, XI, and XII are more difficult to examine in the acute care of the maxillo­facial trauma patient. Vocal cord paralysis and voice changes may be caused by injury to the vagus nerve either locally at the larynx or more inferiorly in the upper chest. PowerPoint Presentation: THORACIC REGION the chest wall and the movement of the thorax should be inspected during several complete cycles of respiration. Fractured rib segments will produce painful breathing in the conscious patient ABDOMINAL/ PELVIC REGION Examination of the abdomen and pelvis is more revealing when the trauma victim is conscious. Pain, rebound tenderness, and pain in the pelvic region with movement are all indicators of lower torso trauma. In both conscious and unconscious patients, ultrasound and CT scans are the gold standard, noninvasive diagnostic techniques to diagnose abdominal injury. PowerPoint Presentation: EXTREMITIES, MUSCLES, AND JOINTS Loss of motion and pain are signs of extremity injury. Obvious open extremity injuries are given a high priority in the order of injury management. Open large bone fractures are treated in the early hours after injury. Examination Of The Face, Neck, And Oral Cavity : Examination Of The Face, Neck, And Oral Cavity Caranial Base Craniofacial trauma victims are often neurologically impaired, intubated, or otherwise unable to provide a contributory history of the events of their accident, a review of systems, or other information that would aid in the diagnosis and treatment of their injuries. The following fundamental physical examination principles are applied :- Facilitate the examination by exposing the patient and removing debris and blood stains. Caranial Base. : Caranial Base. Inspect the head and neck region completely, carefully observing for posterior neck, scalp, and globe injuries. Identifying globe and internal ear injuries is more difficult in the neurologically compromised patient who cannot provide subjective complains of visual or hearing impairment. Palpate all the bones of the head and neck, and displace edematous tissue with firm direct pressure. Establish Le Fort level mobility, step defects, crepitus, facial bone displacement, and comminution. Inspect the forehead region for obvious defects or depressions. Palpate the brow and forehead area to tactilely identify depressions or bone fragments that cannot be visualized because of edema. Midface : Midface Early evaluation of the eye for general function and injury is hierarchically extremely important in the care of the maxillofracial trauma patient. The volume integrity of eye should be established and any findings suggestive of a "soft eye" warrant an early ophthalmology consultation. Observations of the pupil and the anterior eye for injuries described earlier should be completed. Confrontational examination of the extracular muscles of the eye should be completed in an awake cooperative patient. Diplopia in upward and outward gaze is a strong indication of orbital floor fracture and muscle entrapment. PowerPoint Presentation: Subconjunctivial echymosis extending along the entireconjunctival field is a sign of zygoma fracture. visual acuity should be assessed using standard eye charges. Mobility of the midface when the maxillary dentition is manipulated can produce Le Fort I, II or III mobility. Step defects in the orbital rims that are palpable in both a static position and when mobility is introduced further confirm midface fractures. Periorbital edema and ecchymosis can result from scalp, cranial base, and orbital fractures. NOSE: NOSE The external and internal nose should be evaluated by : Establishing a preaccident nasal history, including previous trauma, cosmetic surgery, allergic rhinitis, and nasal ring piercing. Inspecting the nose to observe for obvious deviations of the nasal tip, dorsum depressions, edema and other contour changes. Manipulating the nasal complex to elicit mobility and to palpate step deformities. Using a nasal speculum and good light to examine the internal nose, observing for septal deviation, mucosal tears, and hematomas Intransal lacerations must be identified and repaired. Mucosal hematomas must be decom pressed and tamponaded. Looking for CSF rhinorrhea EARS : EARS The ear should be examined for Lacerations of the auricle, external auditory canan and tympanic membrane. CSF leaks, bleeding, and foreign bodies External auditory canal tears that require repair stabilization with a simple ear wick. ORAL CAVITY AND LOWER FACE Preauricular Upper and lower jaws, Dentoalveolar and Intraoral soft tissue. Preauricular : Preauricular Fractures of the mandibular condyles, and internal derangements and hematomas of the temporomandibular joint should be suspected when the accident circumstances are predictive of injury at these anatomic sites. patient complaints of ear tenderness, preauricular pain to palpation, difficulty opening the jaw, and altered bite are all indicators of condyle injury. bone mobility in the upper ramus region, deviation of the jaw on wide opening, altered occlusion, and open bite and compelling findings suggestive of condyle fracture(s). Preauricular: Preauricular Upper and Lower Jaws. Lip numbness, bite changes, jaw pain, trismus, and swallowing difficulties are common complaints of patients with Le Fort I or horizontal mandible fractures. Sublingual ecchymosis, step defects, mobility of the fracture segments, altered occlusion, intraoral and extraoral swellings, abnormal V1 and V2 nerve findings, and facial contour changes are routine occurrences in fractures of the lower face. Dentoalveolar. : Dentoalveolar. Injuries to the teeth and supportive alveolar bone easily go undiagnosed by dentally un trained emergent and urgent car providers in the hospital emergent and urgent care environment. During the primary survey teeth and tooth fragments must be accounted for to prevent aspiration from occurring or to heighten suspicions about a tooth fragment displaced into the laryngeal pharyngeal region or into the lungs. The following dentoalveolar evaluation can be useful: PowerPoint Presentation: If possible, establish a preinjury oral health history. Count the number of teeth and attempt to establish evidence of fresh tooth fracture and missing tooth segments. Identify grossly mobile teeth, teeth in the line of fracture, and impacted third molars. If possible, establish the health history of impacted mandibular third molars in the line of mandibular body-angle fractures. Probe the distal gingival tissue of the mandibular second molars to establish a communication orally with the impacted tooth. Observe for signs of chronic pericoronal inflam­mation and radiographic evidence of third molar abnormality. PowerPoint Presentation: Establish the presence of labial, lingual, and palatal lacerations and their potential to compromise the blood supply to dentoalveolar fracture segments. Further account for avulsed teeth either in the oral cavity or in the patient's or escort's possession. Create a time line for avulsed teeth and establish how the avulsed tooth was retrieved and trans­ported (Figure 15-6). Locate dentoalveolar fracture segments and estab­lish their viability and prognosis. Intraoral Soft Tissue. Evaluation of intraoral health, disease, and injury can be executed by observ­ing for swelling, the integrity and patency of salivary gland ducts, lacerations, foreign bodies, and neuro­logic injuries. Substantial swelling of the tongue and the nasopharynx or the potential for substantial airway-obstructing swelling should be identified early and protective airway measures taken. Initial Clinical Intervention : Initial Clinical Intervention Intraoral wounds and extraoral lacerations that communicate intraorally should be cleaned, probed, and injuries to salivary gland ducts and the facial nerve diagnosed. Extrinsic or intrinsic foreign bodies should be located and their immediate danger to the patient established. Active, aggressive bleeding should be controlled by pressure or, if prudent, by electrocautery or surgical measures. Salivary gland duct potency should be evaluated using lacrimal probes and the quantity and quality of salivary flow should be determined. Extraoral Soft Tissue: Extraoral Soft Tissue Careful and thorough inspection of the soft tissues of the head, face, and neck is an important part of examining patients suf­fering from maxillofacial injuries. Soft tissue injuries can be evaluated from several perspectives, including identification of the wounding agent, whether the wound clean or dirty, the type of wound, the presence of foreign bodies and debris in the wound, tissue loss, the survivability of severely damaged soft tissue, associated adenxal and deeper structure injuries, anciated skeletal fractures. Wounding Agent: Wounding Agent Traumatic wounding issue is potentially much more destructive than surgical wounding. Scarring and postrepair loss of function will be greater in patients who have received chemical or thermal skin injuries or avulsive high velocity gunshot wounds. A sharp clean knife wound to the cheek can be repaired with an outcome as favorable as the closure of a surgically induced wound. Clean or Dirty Wound: Clean or Dirty Wound Identifying the events associated with the wounding is as important to the outcome of wound repair as is the surgeon’s careful examination of the injury. Road debris, for example may be found in the facial wounds of a motor vehicle accident (MVA) victim ejected from an auto. Macroscopic road debris soiling a facial laceration may be less of a contaminant than muddy pond water. The surgeon who is diligent in establishing that the MVA victim with a facial laceration exited the car through the windshield will be prepared to search more vigorously for glass shards. Early vigorous lavage and foreign body removal will reduce infection and scarring. Type of Wound : Type of Wound Lacerations that are confined to cosmetically forgiving anatomic facial units and located in natural skin lines are easier to repair. Wounds can be classified by location, depth, liner measurement, wound margin appearance, and actively bleeding status. Laceration repair, independent of would type, is ideally completed as early as possible after the wound is sustained. Foreign Bodies: Foreign Bodies Foreign bodies should be classified by type, location, and their potential as an infecting agent. A high-velocity bullet fragment lodged deeply in the soft tissue of the tongue will usually be well tolerated by the body if left in place compared with the wadding from a shotgun blast imbedded in a macerated wound in the cheek. In the former case, searching for a bullet fragment deep in the tongue is potentially more threatening to the patient than the risks of no immediate treatment. Tissue Loss: Tissue Loss Avulsive facial tissue wounding is particularly problematic and is often associated with underlying skeletal injury. Careful attention must be applied to the consequences of primary closure of avulsive wounds that are repaired at the expense of distorting adjacent anatomic units. Complex wounds may be best treated in stages by initially cleaning and packing the would with moist sponges. The patient is then prepared for a complex wound closure with grafts of flaps.

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