TCP Week 6 (Trauma)

primary survey for maxillofacial trauma (ABCDEs)

Airway: Assess movement of air/ obstruction

Disability: Examine pupillary response (are they equal? are they reactive?)

the most important consideration for maxillofacial trauma is

AIRWAY MANAGEMENT

- have anesthesia on hand for trauma

- if facial trauma, evaluate patient for head injury

Maxillofacial, neck, or laryngeal trauma:

- What can cause airway obstruction?

- Initially assess?

- Intubate when?

Maxillofacial, neck, or laryngeal trauma can cause airway obstruction: B/L mandible fractures can cause airway obstruction

Initially assess "the talking patient": Appropriate response means a patent airway, intact ventilation, and a perfused brain

Patients with AMS or facial trauma require a definitive airway until fully assessed: GCS less than 8, intubate

picture of GCS score again

definitive airway steps & 3 types?

1. Tube placed in the trachea

2. Cuff inflated below the vocal cords

3. Connected to a form of oxygen-enriched ventilation

4. Secured with tape / tube holder

3 types:

- Nasotracheal

- Orotracheal (MC)

- Surgical airway

secondary survey (history of MOA)

More detailed exam after primary survey:

- Facial pain?

- Blurred vision?

- Dysphagia?

- Nasal congestion?

- Facial numbness?

- Nasal congestion?

- Facial Numbness?

- Malocclusion?

- Painful teeth?

- Vertigo?

secondary survey (PE)

- Facial edema

- Lacerations

- Rhinorrhea

- Periorbital edema

- Periorbital ecchymosis "Racoon eyes"

- Facial bone instability (palpate face)

- Nasal deviation

- Otorrhea

- Periaricular ecchymosis "Battle's Sign"

diagnostic studies for facial injuries

CT facial bones:

- injuries can be seen on CT head; however, CT facial bones provides more views and better diagnostics

- allows for pre-operative planning

Panorex:

- series of x-rays used to evaluate isolated mandible, dental, or alveolar ridge fractures

- more often used post-operatively for surgical planning (not done in trauma bay)

ocular traumas and what to look for when these patients first enter the trauma bay

Orbital bone fractures: Blow out fractures

EOM entrapment

Globe rupture

Eye penetration

Evaluate eyes early, as peri-orbital swelling occurs quickly and can obscure later exam

orbit is made of what bones?

frontal bone (roof/superior rim)

sphenoid bone & zygoma (lateral)

zygoma & maxilla (floor)

ethmoid & maxilla (medial)

management of orbital bone fracture

CT localizes fractures

Consult placed to OMFS: Orbital floor "blow out" fractures usually need surgical repair

Avoid excessive eye pressure!

May apply ice packs to ease swelling

ocular muscle entrapment

- Occurs when eye muscles become trapped within a fracture (most commonly inferior rectus muscle)... requires urgent response

- Results in inability to actively move eye within all fields

warrants surgical exploration if there is no movement, let OMFS know

how does globe rupture present on PE

- decreased visual acuity

- pupillary defect

- teardrop pupil

- extrusion of vitreous fluid

- gross deformity of eye

management of globe rupture

Requires STAT ophthalmology consult

Goal is to decrease intraocular pressure!

- elevate HOB, do not apply any pressure dressings

- avoid placing any medication or diagnostic eye drops into the eye

Place an eye shield over affected eye until evaluated by ophthalmology

orbital hematoma

Causes loss of vision:

- Compartment syndrome of the eye

- May require lateral canthotomy to decompress orbit

eye penetration

- can cause?

- what to do with foreign bodies?

- imaging?

Can cause globe rupture

Any foreign bodies should be left in place, removal should be deferred to the ophthalmologist

Image with CT: Avoid MRI (may move metallic objects, takes more time than CT, more artifact movement)

Management of eye penetration

- Keep patient NPO

- Prophylactic antibiotics (Vanco & 3rd or 4th gen Cephalosporin) or Floroquinolone

- Tetanus prophylaxis

- Ophthalmology consult (may require transfer to tertiary center)

- Globe rupture and/or penetration will require surgical repair

nasal trauma includes

Nasal bone fractures

Cribriform fractures

Epistaxis

- Anterior

- Posterior

nasal bone fracture PE findings

may reveal nasal crepitus, deformity, edema

nasal bone fracture diagnostics

CT

management of nasal bone fracture

Ice & head elevation

Displaced fractures: ENT consult (may require closed reduction)

Nasal splint (may be internal or external to provide support)

management of nasal bone fracture: septal hematoma

Septal hematoma may require drainage to prevent necrosis.

Drainage then requires nasal packing for 2-3 days (while edema goes down)

cribiform (ethmoid) fractures

- findings on PE

- diagnosed with?

- Exam may reveal CSF rhinorrhea

- Diagnosed via CT scan

cribiform (ethmoid) fractures management

- these patients CANNOT have NG tubes placed (risk of tube entering brain)

- keep head of bead elevated 40-60 degrees to decrease ICP

- may result in loss of smell

**DO NOT discharge... concern for meningitis bc of disruption in bone at base of skull.

management of anterior epistaxis

pinch nose, wait 5-10 minutes minimum:

- if bleeding persists, consider nasal packing

- may also use cautery

management of posterior epistaxis

consider consult to ENT or OMFS for placement of balloon catheter

Facial bone fractures

Majority of facial fractures do NOT require surgery

•Mandibular fractures

•LeForte fractures

•Sinus fractures

•Facial nerve injury

•Facial lacerations

which facial fractures require hospitalization and how are you managing them?

Nasoethmoid fracture: Monitor for CSF leak and risk of meningitis

Zygomatic arch fracture: Monitor for airway complications

LeFort fractures: Often require surgical repair

Facial fractures along with additional traumatic injuries

mandible fracture PE findings and imaging

- Malocclusion of jaw indicates mandible fx (can't close mouth)

- CT to evaluate extent of fracture

mandible fracture management

- Requires OMFS consultation

- Prophylactic antibiotics suggested (bc oral bacteria)

- Surgery requires ORIF mandible with plates and/or wires (2 screws above, 2 screws below, and not through)

LeForte 1 fracture (definition and symptoms)

traverse fracture through maxilla above roots of teeth

symptoms: malocclusion

LeForte 2 fracture definition

fracture extends through maxilla, nasal

bridge, lacrimal bones, orbital floor and rim

LeForte 3 fracture definition and symptoms

fracture than involves complete discontinuation of skull from the face

extends through nose and along medial wall of orbit, through floor of orbital and through lateral orbital wall and zygomatic arch, and through sphenoid

may involve CSF leak!!

management of sinus fracture

facial fx may extend into sinuses

require prophylactic antibiotic

sinus precautions (to minimize pressure w/in sinuses):

- Nothing inserted into nose

- Do not blow nose

- No drinking through straw

- Sneeze with mouth open

- No smoking

CN VII

motor branch of facial nerve

CN V

trigeminal nerve: sensation of facial nerve

acute facial paralysis

- suggests?

- requires?

suggests facial nerve transection

requires immediate consultation with maxillofacial surgery

management: small simple facial lacerations

lacerations should be closed

management of large complex facial lacerations or avulsions

should be closed by plastic surgery, if available

what should you use for local anesthesia for facial laceration repair

Lidocaine 1%

DO NOT use epinephrine on facial structures (restricts the small capillaries)

eyelid lacerations (extending through eyebrow) require

closure by plastic surgery or ophthalmology

within 48 hours after injury!

steps to closing a laceration

1. Select your desired sutures, set up sterile field; you'll need:

- suture (0 is largest (dental floss), 60 is fine (like hair))

- needle driver

- pick-up forceps

- scissors

- needles and syringes to inject anesthetic

2. Irrigate the wound with saline/diluted hydrogen peroxide or betadine

3. Prep the area with antiseptic solution - open wounds should be cleaned and prepped with betadine solution (no alcohol solutions on the face or mucosal membranes)

4. Drape the area after prep dries

5. Inject local anesthesia into the lacerated edges to perform a field block

6. Debride any nonviable tissue

7. Start your closure - subcutaneous layer, if necessary or superficial closure

8. Apply antibiotic cream (Bacitracin) and apply desired dressings

lip and tongue lacerations: management

simple small lacerations: can be primarily closed

complex lacerations traversing tongue: closed by OMFS

prophylactic antibiotics should be given due to introduction of oral flora

jaw dislocation may result from

opening the mouth too widely

once the condyle of the jaw is dislocated ______________ prevent self-reduction

muscles of mastication

management of jaw dislocation

- Patient will require sedation

- Reduction achieved by placing thumbs overtop occlusal surface of teeth and pulling downward on the mandible then guiding posteriorly and superiorly back into temporal fossae

DO NOT attempt to reduce fractured mandibles

avulsed teeth and fractures are among ____________ in trauma patients

lowest priority

partially avulsed teeth should be

removed to prevent aspiration:

- only remove those easily done with gloved fingers

- DO NOT attempt to use any tools for removal

ellis 1 tooth fracture

involve enamel of tooth (least severe)

- painless

- evaluated outpatient

ellis 2 tooth fracture

yellow dentin exposed

- Pain

- Cover with calcium hydroxide & foil and refer outpatient

- Avoid solids

ellis 3 tooth fracture

Exposes dental pulp (most severe)

- Extremely painful

- Requires evaluation by dentist or orthodontist within 48 hr

alveolar ridge fractures results in

results in a group of teeth being dislodged

instability of the upper alveolar ridge can indicate

mid-face fracture

instability of the lower alveolar ridge can indicate

mandible

management of alveolar ridge fractures

- these fractures require stabilization with wires, arch bras or splinting by oral surgery

- DO NOT allow patient to eat or drink until fixation

- open fractures warrant prophylactic abx

laryngeal trauma PE

clinical triad:

- Hoarseness

- Subcutaneous emphysema

- Palpable fracture

management of laryngeal trauma

- Requires emergency intubation

- Can be diagnosed by CT if not obvious on exam

tympanic membrane rupture PE and treatment

- Use otoscope to examine TMs during secondary survey

Physical exam:

- TM perforated

- Hemotympanum

Treatment:

- Leave clots in place

- DO NOT irrigate

- ENT consultation

ear lacerations management

- Provide copious irrigation

- Debridement as necessary

- Closure to cover exposed cartilage and preserve cosmetic appearance (often plastic surg)

Avulsion, lacerations extending into ear canal, lacerations with middle or inner ear injury, or evidence of basilar skull fractures should be seen by plastic surgery and/or neurosurgery

primary survey of chest injury

Airway: ensure no obstructions

Breathing: assessing for bilateral breath sounds, equal chest expansion

Circulation: presence of pulses (central and peripheral)

Initiate ECG monitoring to assess for dysrhythmias

pneumothorax definition

Accumulation of air between the visceral and parietal pleura of the lungs

Can occur from blunt or penetrating trauma

pneumothorax results in

ventilation/perfusion defect:

- blood perfuses non-ventilated areas, resulting in un-oxygenated blood returning to the heart

- hypoxia results from poor perfusion

tension pneumothorax occurs when

a laceration in the lung creates a "one-way valve" for air to leak into the chest wall and accumulate under pressure

places pressure on to mediastinum

important to recognize early!

clinical diagnosis of tension pneumothorax

high index of suspicion based on symptoms to proceed with life-saving treatment

s/sx of tension pneumothorax

Symptoms include:

- Chest pain

- "Air hunger"

Signs include:

- Severe respiratory distress

- Tachycardia

- Hypotension (due to pressure placed on

mediastinum)

- Tracheal deviation AWAY from effected side

- Unilateral breath sounds

- Hyperresonance to percussion

- Neck vein distention (due to pressure

placed on mediastinum)

- Cyanosis

management of tension pneumothorax

DO NOT delay treatment for CXR!!!

Treatment: Needle Decompression

- Rapidly insert large bore (14g) needle into the 2nd ICS in the mid-clavicular line of the effected side (just inferior to clavicle)

- Keep catheter in place until a surgical chest tube has been inserted

- Once decompressed, then obtain CXR

cardiac tamponade definition

When a penetration or lac of the cardiac muscle allows blood to leak from the heart into the pericardial sac, causing pressure to build around the heart

Built up pressure prevents the heart from adequately filling & emptying

Decreased CO

Results in hypoxia

s/sx of cardiac tamponade

Symptoms:

- Chest pain

- SOB

Signs:

Beck's Triad:

- venous pressure elevation (blood can't get in)

- declined arterial pressure (blood can't get out)

- muffled heart tones

Kussmaul's sign: inc venous pressure with inspiration

dx and tx for cardiac tamponade

Dx:

- EKG

- FAST U/S

Tx:

• Pericardiocentesis: smaller effusion or no surgeon available

• Emergency thoracotomy: Large effusion with loss of vital signs

• Surgical repair of cardiac laceration: definitive treatment

pericardiocentesis

- Needle drainage of the pericardial sac

- Use 16-18g long needle to drain sac

- Place drainage tube until patient can be transferred to definitive care

indications of emergent thoracotomy

May be performed only under certain situations

- Relief of large pericardial effusion

- Direct control of exsanguinating intra-thoracic hemorrhage

- Open cardiac massage (manual CPR)

- Allows cross-clamping of aorta to increase perfusion to heart and brain

ED thoracotomy followed by OR exploration of wounds

contraindications of emergent thoracotomy

- Absence of qualified surgeon

- Blunt chest trauma with pulseless electrical activity (low chance of survival)

- Penetrating wounds with no electrical activity on EKG

- No signs of life (reactive pupils, spontaneous movement, organized EKG)

secondary survey after cardiac tamponade

- CXR

- ABG

- EKG

- Bloodwork, including Troponin

- CT scan of the chest once patient has been determined to be hemodynamically stable

simple pneumothorax

- accumulation of air within pleura, described as a % of lung collapsed

- can convert to tension PTX under positive pressure ventilation

you should perform a CXR after surgery

open pneumothorax

aka "sucking chest wound" (can see lac of chest and airflow)

requires placement of occlusive dressing, overtop of wound, secured on 3 sides

hemothorax

- Accumulation of blood within the pleural space

- Most commonly occurs due to lung laceration or laceration of intercostal vessel

- Can be associated with thoracic spine fractures

diagnostic studies for pneumothorax/hemothorax

CXR: A/P view

CT chest w/ IV contrast

s/sx of pneumothorax and hemothorax

Symptoms:

- SOB

- Chest pain

Signs:

Pneumothorax: decreased breath sounds, hyperresonance to percussion

Hemothorax: decreased breath sounds, dullness to percussion

CXR pic of pneumothorax

CT scan of pneumothorax

CXR of hemothorax picture

small hemothorax treatment

observation and serial CXR

large hemothorax treatment

Chest tube insertion to accurately monitor blood loss and need for OR exploration

OR criteria for hemothorax?

- 1500mL initial output when CT was placed

- Loss of 200mL of blood per hour x 2- 4 hours

- Requires multiple blood transfusions

treatment for pneumothorax (

often only detected on CT scan:

can be observed with serial CXR

treatment for pneumothorax (10-30% collapse)

call radiology to do IR drain

treatment for pneumothorax (>30% collapse)

requires insertion of surgical chest tube

treatment for a contained pneumothorax

consider interventional radiology to insert ultrasound guided chest tube (pigtail)

chest tubes/thoracostomy tubes

Placed into the 4th or 5th intercostal space, within the anterior mid-axillary line at the bedside with use of analgesics (IV pain medication and local)

Negative pressure contained system allows for lung re-inflation

Initially placed to wall suction then transitioned to "waterseal" prior to removal

If lung fails to reinflate with chest tube, may need OR and pleurodesis (glue lung tissue to chest cavity)down the road

s/sx of lung contusion

Symptoms:

- chest pain

- SOB

Signs:

- Chest wall contusion

- Commonly occurs with rib fx

- SpO2 less than 90% on room air

lung contusion diagnosis and treatment

Diagnosis:

- serial CXR

- Chest CT (will show difference between contusion and hemothorax)

Treatment:

- Serial CXR

- SpO2 monitoring

- Patients with low SpO2 and chronic lung conditions may require intubation and ventilator support

blunt cardiac injury/cardiac contusion diagnosis and treatment

can range from clinically silent injury, transient arrhythmias, to cardiac wall rupture

Dx:

- EKG

- FAST exam (US)

- Troponin

- Echocardiogram

Tx:

- Management of arrhythmias

- Evaluation by cardiac surgeon

- Management of MI

s/sx of sternal and rib fractures

Symptoms:

- severe chest pain

- back pain

- SOB (worse with deep breaths from rubbing)

Signs:

- Crepitus on chest wall palpation

- Chest wall contusion

- Low SpO2

flail chest (definition and what it causes)

fracture of 2 or more adjacent ribs in 2 or more places

causes:

- paradoxical movement

- inadequate ventilation

- hypoxia

sternal and rib fractures diagnosis and treatment

Dx: CXR and CT chest

Tx:

- Analgesia/Pain Meds! so they breathe and don't dvlp PNA!

- Repeat CXR

- Incentive Spirometry

- Intubation & ventilatory support for patients with multiple rib fx/lung disease

OR:

- Open reduction of rib fractures (rib plating)

signs of tracheal/bronchiole injuries

- Hemoptysis

- Chest wall subcutaneous emphysema (disruption to trachea)

- Tension PTX (chest tube and lung still doesn't re-inflate)

- Failure of lung to re-expand after chest tube placement

HIGHLY FATAL

tracheal/bronchiole injuries diagnosis and treatment

Dx: Bronchoscopy

Tx:

- Intubate (opposite main stem... only oxygenate one side)

- Operative repair trachea

aortic injury notes

- Highly fatal injury, cause of many DOA on scene

- Those who survive typically have an incomplete tear with a contained hematoma

- No specific s/sx

- High index of suspicion for those with decelerating forces (high falls)

aortic injury diganosis and treatment

Dx: Helical CT chest with contrast

Tx: primary repair of torn segment or endovascular repair by vascular surgeon

major vessel injuries management

- may require emergent thoracotomy

- cross clamping of vessel

- emergent OR exploration with repair of lacerated vessel