OMFS Interns 2020-Book

Club (Corona edition)

Justin Sedaghat
Columbia DDS 2020
UMiami/Jacksom Memorial OMFS
 Welcome!
Goals are to get a solid understanding of Trauma for our OMFS residencies

Each Zoom Meeting will meet Monday Wednesday Friday @ 4PM EST (1PM for west
coasters)

There is a lecturer for each, who will prepare a powerpoint going over the assigned chapter.

Write down questions and thoughts for discussion

Possibility down the line of other textbook readings...Any recommendations?

Good time to meet for people?

Thanks for Tyler Jacobs for helping me set this up

PERI-OPERATIVE
MANAGEMENT OF THE
CRANIO-MAXILLOFACIAL
TRAUMA PATIENT
Oral and Maxillofacial Surgery-Fonseca Volume 2, Second Edition
CHAPTER 1
Death as a result of trauma
● Trimodal distribution
○ Time of injury→ result of brain, brain stem, spinal cord, heart, or great vessel injury
○ Within minutes to hours---> Rapid transport, assessment, and intervention may greatly improve survival
■ Subdural/epidural hematoma
■ hemothorax/pneumothorax
■ Pelvic fractures
■ spleen/liver lacerations
○ Days to weeks
■ Sepsis and multiorgan failure
Assessment-Primary Survey (initial assessment)
Immediate identification and management of all life-threatening issues

● Must assume:
○ There are multiple injuries
○ The physiologic state of the patient is impaired
○ The condition of the patient might worsen rapidly
● Injuries: Most obvious is not the most critical
● Should take no longer than 5-10 minutes
○ A detailed secondary head-to-toe assessment will be performed later
 Assessment-Primary Survey
A, B,C D,E

● AIRWAY
● BREATHING
● CIRCULATION
● DISABILITY
● EXPOSURE
 Primary Survey-Airway
● Comes with early establishment of c-spine stabilization
● Supplemental Oxygen immediately and Pulse Oximetry
● Exam
○ Face, mandible, larynx, trachea
○ Look for foreign bodies, compromising facial fractures, or soft tissue injuries
● Use a jaw thrust or gentle chin lift
○ To protect C-spine
● Nasophranygeal (NPA) airway good for Conscious patients
● Orophrangeal airway (OPA)
Maxillofacial Trauma-Unique Complications
● Foreign bodies & blood in the airway
● “Flail mandible” or Multiply fractured mandible
○ Fracture of symphysis + bilateral condyles, rami, or angles
○ Potentially compromised airway with pharyngeal hematoma, loss of tongue
maintenance
● Patients who refuse to lay supine→
○ May be indicating inability to maintain airway
 Laryngeal Fracture
● Rare cause of airway obstruction
○ an infrequent injury due to the high mobility of the larynx and the protection it receives from the
surrounding bony structures of the sternum, mandible, and cervical spine
● Indications
○ Hoarseness and subcutaneous cervical emphysema
○ Palpable fracture
○ Stridor
○ Absence of breathing
When to place a definitive airway, when surgical?
 When to place a definitive airway

● Severe head injury (GCS<8)

 Definitive airway
● Tube inserted into trachea with cuff inflated
○ guard against aspiration and obstruction
○ Provides assisted ventilation
● Can be Surgical or non surgical

RAPID SEQUENCE INDUCTION

● Pre-oxygenate
● Administor cricoid pressure
● Administer 1-2 mg/kg succinylcholine, IV
● Intubate
● Inflate cuff and confirm tube placement
● Release cricoid pressure
Surgical
● If nonsurgical is unsuccessful
● Indications
○ Glottic edema
○ Oropharyngeal hemorrhage
○ Foreign bodies
○ Laryngeal fractures
● Surgical cricothyroidotomy
○ Preferred for emergency
○ Easier than tracheotomy
○ Less bleeding, quicker
○ Contraindicated in peds
● Needle cricothyroidotomy
○ Emergency situations
vs Nonsurgical Airway
● Two person intubation
technique
○ One provides stabilization of
c-spine
○ Other performs orotracheal or
nasotracheal intubation
● Avoid nasotracheal if upper or
midface and cranial base
fractured are suspected
● Surgical cricothyroidotomy
○ Preferred for emergency
○ Easier than tracheotomy
○ Less bleeding, quicker
○ Contraindicated in peds
● Needle cricothyroidotomy
○ Emergency situations
○ Not adequate ventilation,
temporary
AIRWAY-KEY POINTS (aka high yield)
● Be prepared to secure an airway in all injured patients.
● Treat all patients as though they have a cervical spine injury.
● Continuously re-assess airway patency
○ when in doubt, secure the airway
● Avoid prolonged apnea; be prepared to secure a surgical airway.
 B-BREATHING
● Lungs, chest wall, and diaphragm all contribute to normal gas exchange
● Chest and abdomen must be EXPOSED
○ Obvious wounds should be dealt with immediately
○ Look for paradoxical movements or abdominal breathing
■ Chest wall or spinal cord injury possible
● Auscultate→ ensure adequate, bilateral gas flow
● Percussion → may reveal fluid or air in chest
● PALPATE→ tracheal deviation, or chest wall crepitus
○ May indicate pneumothorax or rib fractures
 Breathing- KEY POINTS
● Problems with ventilation w/ successful intubation→ think thoracic
trauma
● MAKE SURE TO EXPOSE and Examine Chest and Abdomen
● “If you can’t see it, you can’t treat it.”
C-Circulation
● Hemorrhage is most common cause of post-injury death
○ Look for hypotension, tachycardia is nonspecific
○ Also monitor patients Conciousness, and skin color
● External bleeding→ direct pressure
● Place 2 large-bore peripheral IV catheters to allow for fluid resuscitation
○ Begins with a 1000-mL bolus of crystalloid solution or 20ml/kg for a child
C-Circulation-Extremes of age
● Children compensate very well
○ Substantial reserves
○ Tachycardia up to 180 bpm
○ Decompensation when it does occur is sudden and difficult to recover from
● Geriatrics have decreased ability to compensate
○ Decreased sensitivity to catecholamines
○ CCB and beta blocker meds can blunt compensatory effect
 C-Circulation-Shock
● “presence of inadequate organ perfusion and tissue hypoxia
resulting in end organ damage”
● Key to prevention is identification of cause
● Impending shock
○ Systolic blood pressure is NOT indicative
○ Mottled skin, delayed capillary refill (normal is <2 sec), tachycardia
● Can be hemorrhagic or non-hemorrhagic
○ non-hemorrhagic→ cardiogenic, neurogenic, septic
○ Imaging studies can help indicate (CT, US, plain films)
 C-Circulation-Hemorrhagic Shock Classification
● Classified based on percentage of total blood volume lost
○ Determined by clinical signs

● Class I Hemorrhage ● Class II Hemorrhage ● Class III Hemorrhage ● Class IV Hemorrhage

○ <15% blood loss ○ 15-30% blood loss ○ 30-40% blood loss ○ >40% blood loss
○ No changes in BP ○ Tachycardia, tachypnea ○ Tachycardia, tachypnea ○ Severe hypotension,
or HR ○ Increase in diastolic BP ○ Decreased pulse pressure narrow Pulse pressure
○ Healthy pts ○ Narrowed pulse ○ Hypotension ○ Tachycardia
equilibrate within pressure from surge of ○ Delayed capillary refill, ○ Cool pale skin
24 hrs catecholamines decreased urine output ○ Urine output→ 0
○ Mental status stable ○ AMS ○ Tx: emergency sx to find
○ Tx: resuscitation with ○ Tx: Transfusion required and treat cause and
crystalloid multiple transfusions
Hemorrhagic Shock Classification
Circulation
● Place urinary catheter and monitor urine output
○ .5 mL/kg/hour is the minimum tolerated
○ Give more crystalloid or blood to maintain this
● Mental Status doesn’t change until SBP falls under 55-60
○ Due to cerebral autoregulation
Circulation-Key Points
● Obtain adequete vascular access ASAP
● In a trauma patient→ assume shock is hemorrhagic unless proven otherwise
● Initiate treatment before appearance of hypotension
○ ACT EARLY!
 D-Disability (Neurologic Status)
AVPU
● A-Alert
● V-responds to Verbal Stimulus
● P-responds to Painful Stimulus
● U-Unresponsive

Better assessed once patient is hemodynamically stable

Sedative and paralytic agents for intubation can interfere w/

GCS scoring

Neurologic deterioration can be sudden and rapid

Frequently re-evaluate
E-Exposure/Environmental Control
Completely expose the patient

Perform head-to-toe examination

Record body tempoerature and monitor

Identify sites of internal and external hemmorhage→ bleeding, fracture, ecchymosis

Keep the patient warm→ blankets

Secondary Survey
● Begins once patient is stabilized
● Systematic head-to-toe and front-to-back examination
● Reassessment of ABCDE’s is continuously carried out
● Take a thorough history→ AMPLE
○ Allergies
○ Medications
○ Past illnesses/pregnancy/operations
○ Last meal
○ events/environment related to injury
 Maxillofacial Injuries
● Facial fractures can make speech intelligible
○ Difficult to assess neurological status
● Even after appropriate hemostatic maneuvers→ uncontrolled bleeding may require interventional
angiography
● Treatment is usually deferred until all life threatening injuries have been adressed
● Examination can begin as soon as patient is stabilized
● HEENT exam
Head Exam
● Clean of all blood, debris, foreign bodies
● Soft tissue injuries noted
○ Abrasions, contusions, burns, avulsions, and lacerations
○ Lacerations and avulsions→ check for involvement of vital structures
■ Nerves, parotid gland, duct
● Craniofacial skeleton
○ Look for steps, discontinuities, movement, and loss of projection
○ Check:
■ Cranium, fronto-orbital bandeau, naso-orbital complex, zygomatic angulations, mandible
Eye Exam
● Visual loss is potential risk→ 40% of midface fractures involve orbit
● Difficult to exam once edema has set in
● Visual acuity examined with pocket-sized card @ 14 inches
● Note: spectacle hematomas and subconjunctival hemorrhage--------→
● Look for the following:
○ Restriction of eye movement
○ Vertical dystopia -------------→
○ Diplopia
○ Pupillary size
■ Direct and consensual response
Eye Exam
● Fundoscopic exam
○ Indicated increase in ICP, retinal detachment, or ischemic injury to optic nerve
● Proptosis------------------------------------------------------------------------>
○ Suggests hemorrhage within orbital walls
○ In combination with: tense globe, ocular pain, decreased visual acuity, dilated pupil
■ THINK RETROBULBAR HEMORRHAGE
■ Surgical emergency→ requires lateral canthotomy and cantholysis
● Medial injuries
○ Exam for canalicular system
● Lateral Upper lid injuries
○ Involvement of lacrimal gland
● Rule out ruptured globe
○ Get ophthalmologic consult
 Ear Exam
● Auricular hematoma should be diagnosed rapidly
○ Avoid “cauliflower ear”
● Indicate cranial base fracture
○ Mastoids checked for ecchymosis or Battle’s sign
○ Check for hemotympanum
○ CSF otorrhea
● Laceration of external auditory canal
○ Possibility of condylar injury
Nose/Nerve Exam
● Increase in intercanthal distance→ naso-orbital-ethmoid injury
● Decreased ability to move air through nose→ bony or cartilaginous injury
● Septal hematomas→ diagnose and evacuate early
○ Can lead to septal cartilaginous necrosis and nasal collapse
● Epistaxis treated with:
○ Nasal packing Halo test
○ Direct cautery
○ Rarely transarterial embolization
● Check for CSF rhinorrhea in upright patient→ anterior cranial base fracture
○ DON’T PLACE NP or NG TUBE
○ Halo test or Beta2 transferrin assay
Nose/Nerve Exam

● Check trigeminal nerve

○ Evaluate for anesthesia or paraesthesia
○ Can indicate underlying fracture
● Check corneal reflex (V1)------------------------------>
○ Evaluate brainstem injury
● Check continuity of facial nerve
Throat Exam (Oral Cavity)
● Check occlusion and for missing teeth
○ Rule out aspiration of teeth with plain film of chest
○ Steps and mobility→ dentoalveolar or jaw fracture
● Lateral open bite→ mandible fracture or TMJ effusion/hemarthrosis
● Check Dental midline’s
● Anterior open bite→ may indicate LeFort fracture (I,II, or III)
○ Verify by grasping anterior maxillary teeth with one hand, forehead with other and check for mobility
● CT scans, 3D reconstructions, CT with contrast for vascular injury
 Neck Exam
● Contains many vital structures→ can be immediate threat to life
○ From airway compromise or hemorrhage
● Anterior and posterior triangles of neck→ know your anatomy
● Platysma and SCM are important landmarks
● Vertical zones of neck are divided by 3
● C-Spine should be maintained
Neck Exam-Clinical signs of penetrating neck injury
● Hemorrhage
● expanding hematoma
● Air movement through the wound with breathing
● Subcutaneous crepitus
● Voice changes
● Dysphagia→ difficulty swallowing
● Odynophagia→ painful swallowing

Patients with injuries deep in platysma Zone II are generally taken directly to surgery for exploration

zone I and zone III → preoperative CT angiography or angiography--> rule out significant vascular injury
Neurologic Exam
● GCS should be reevaluated
● Evaluate
○ Level of consciousness
○ Motor and sensory examination
■ Sensation, strength, proprioception, reflexes, tone, coordination
● Don’t be afraid to ask for neurosurgery consult
● Neurologic injuries come from:
○ Concussions, spinal injuries, diffuse axonal injury
○ Epidural and subdural hematomas
○ Hypoxia/ischemia
Intraoperative Management

● Airway management
○ Tube change from orotracheal to nasotracheal
○ Convert cricothyroidotomy→ tracheotomy (debatable)
○ Maxillomandibular fixation (MMF)
■ Tracheotomy required for panfacial fracture patient
■ Submental only if short-term intubation
○ Use armored tube
Intraoperative Management
● Cranio-maxillofacial fractures→ coronal incision
● Use previous incisions
● C-Spine injury patients
○ Must be operated on in C-Collar or head secured to Mayfield headrest
○ Can airplane bed
Postoperative Management-MMF
● Not Ideal for patients with hx of:
○ seizure disorder
○ dementia
○ psychiatric disease
○ pulmonary problems
● Aspiration risk
● Bruxers→ hardware becomes loose→ can be aspirated
Postoperative Management-Tracheotomy Care
● Patients should be encouraged to occlude the tube and speak as
soon as the cuff is deflated
○ Reestablishment of breathing via upper airway
● Passy-Muir valves- one way valves that allow for speech→
● Do a swallowing evaluation→ tube might need to be downsized
● In preparation for decannulation→ tracheotomy tube may be
temporarily plugged
○ Patient should control in the event that respiratory problems
develop.
● Can be removed when→ oral intake and breathing are normal
○ patient told to occlude hole with manual digital pressure while
speaking or coughing
○ Tract closes after ~1 week
Postoperative Management
● Sutures
○ Should be removed 5-7 days
○ to avoid epithelialization of the suture tracts after placement
Postoperative Management-Nutrition
● Post Trauma→ body is in hypercatabolic state
○ Glucose and fat readily depleted
○ Protein broken down→ organ and immune system dysfunction
● Total Parenteral Nutrition if GI tract is not intact
○ Enteric feeding is preferential
● MMF, pharyngeal injury or edema, orocutaneous fistula, or
discontinuity of the jaws
○ May indicate NG tube or liquid diet
● Examine the body habitus for clues about nutrition
● Best indicator for nutritional needs:
○ Caloric and nitrogen balances
Postoperative Management-Nutrition

If possible enteral is preferred

Postoperative Management-Nutrition
● Equation for basal energy expenditure (BEE)

Males: BEE = 66 + (13.7 × weight) + (5 × height) − (6.8 × age)

Females: BEE = 66.5 + (9.6 × weight) + (1.8 × height) − (4.7 × age)

Weight in kg, Height in cm, age in years

Example: 24 yo M, 69 kg, 171 cm

BEE=66+(13.7 x6 9kg)+(5 x 171cm)-(6.8 x 24 years)

=1703.1 calories
Postoperative Management-Nutrition
● Protein restriction is necessary in patients with hepatic or renal failure
● Urine Urea Nitrogen can help determine protein needs
○ ~90% of excreted nitrogen
○ Should be a positive nitrogen balance of 2 to 4 g/day
○ Equations:
■ Protein loss = [UUN + (4 g insensible + nonurea nitrogen loss)]
■ Nitrogen balance = (dietary protein/6.25) − ([UUN/0.08] + 4)
Questions? Suggestions?
THANK YOU!