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Maxillofacial Trauma: From Field to Finish
2017 NOTS Trauma Symposium
FREEDOM JOHNSON, MD, FACSDirector - Oncologic, Reconstructive and Cranial Base Surgery
Depts. of Otolaryngology – Head and Neck SurgeryMetroHealth Medical Center & CWRU
Disclosures
• None
Disclaimers
In this talk I:• WILL
- Provide an overview of Maxillofacial Trauma- Focus on major facial trauma- Share my approach
• Will NOT
- Review Definitive Management- Review Neck Trauma
Learning Objectives
At the conclusion of this talk participants shall:
1. Understand the signs of a potentially life-threatening maxillofacial injury
2. Understand workup and timing issues
3. Understand the long-term sequelae of facial trauma
Outline• Anatomy
• In the Field
• Acute Evaluation & Management
• Subacute/Long-term Management
• Case Examples
Background/Practice• Birth through Medical School - California
Background/Practice
• 2004 - Present: Cleveland!
• Residency @ CWRU/UH
• Fellowship @ Vanderbilt
• Started at MetroHealth 2009
• Practice about equally split:• Oncologic Ablative• Oncologic Reconstructive• Trauma Reconstructive
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Outline• Anatomy
• In the Field
• Acute Evaluation & Management
• Subacute/Long-term Management
• Case Examples
Anatomy
• Soft tissue envelope
https://pocketdentistry.com/wp-content/uploads/285/c2-fig-00101.jpg
Anatomy
• Bony
Copyright © Pearson Education Inc, publishing as Benjamin Cummings
Anatomy
• Vasculature & Airway
https://courses.lumenlearning.com/ap2/chapter/circulatory-pathways/ http://thesistut.com/hard-palate-anatomy.html#
Outline• Anatomy
• In the Field
• Acute Evaluation & Management
• Subacute/Long-term Management
• Case Examples
In The Field
• Triage: Is this life threatening?
• Airway Compromise?
• Bleeding?
• Associated Injuries?
In The Field
• Airway Compromise
In The Field
• Bleeding• External bleeding
• Direct pressure if possible
• Hematoma/Internal bleeding• Control Airway
In The Field
• Associated Injuries• Intracranial• Cervical
In The Field
• Stabilize and Transport• Secure C-Spine• Secure Airway• Direct pressure for external bleeding
In The Field
http://image.cleveland.com/home/cleve-media/width620/img/metro/photo/emsjpg-4b78e972c5e954b7.jpg
Outline• Anatomy
• In the Field
• Acute Evaluation &
Management
• Subacute/Long-term Management
• Case Examples
Acute Eval & Management
• Events On Arrival• History• Workup• Treatment & Timing
Acute Eval & Management
• On Arrival• Standard ATLS• C-Spine
• Secure/Clear• Airway
• Intubate/Surgical airway• Bleeding
• Pressure/Pack/IR
Acute Eval & Management
• History• Mechanism
• Energy: Low vs. High
• Associated Injuries• Team Sport
• Social Circumstances
Acute Eval & ManagementHistory
• Mechanism: Energy• Low energy
• Blunt vs Penetrating• Limited/Predictable tissue injury
• “What You See is What You Get”• Typically single stage
• May 2 stage if extensive
Acute Eval & Management• Low Energy Examples
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Acute Eval & ManagementHistory
• Mechanism: Energy• High Energy
• Penetrating (GSW)
• Unpredictable tissue viability
• Typically multiple stages
Acute Eval & Management
• High Energy: almost always GSW- Ballistic penumbra- Tissue necrosis evolves with time
Acute Eval & Management Ballistic Injury
• Damage to hard and soft tissue• projectile design• distance• velocity
• Trajectory can change
• Transfer of energy/deceleration
Acute Eval & ManagementBallistic Injury
https://i.warosu.org/data/tg/img/0309/32/1395258452114.jpg
Acute Eval & ManagementBallistic Injury
Attribution unknown
Acute Eval & ManagementHistory
• Associated Injuries• Airway
• Direct involvement vs supraglottic obstruction
• Vascular• intracranial vs extracranial• immediate vs delayed
• CNS/C-Spine
• Ophthalmologic
Acute Eval & ManagementHistory
• Social Circumstances• Sets context of recovery
• Support network• Ability to get to rehab• Reliability
Acute Eval & ManagementWorkup/Planning
• Examination• Soft tissue envelope
• Imaging• High Resolution CT• 3D reconstructions• Virtual Surgery• Pre/Custom Bent plates
• Consultation• Gather all experience and resources
Acute Eval & ManagementWorkup/Planning
• Have a Team– Surgical
• Oto-HNS/Plastics• Neurosurgery• OMFS• Ophtho/Oculoplastics
– Non-Surgical• PM&R• Mental Health• Social Work
Acute Eval & ManagementTiming – Low Energy
• Soft Tissue/Composite• Address soft tissue within 24 hrs
• Bone• ~2 - 3 week window for adults• 5 - 7 days for children
Acute Eval & ManagementTiming – Low Energy
• Special cases for early intervention
• CSF Leak
• Flail Mandible
• Orbital entrapment or globe rupture
Acute Eval & ManagementEarly Intervention
• CSF Leak
Acute Eval & ManagementEarly Intervention
• Flail Mandible
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Acute Eval & ManagementEarly Intervention
38
• Orbital Entrapment
https://openi.nlm.nih.gov/imgs/512/117/2892129/PMC2892129
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Acute Eval & ManagementTiming – High Energy
• Immediate (hours to day 1)• stabilization• airway management (trach)• debridement
• Early (days 1 - 7ish)• local wound care• imaging• surgical planning
Acute Eval & ManagementTiming – High Energy
• Intermediate (week 1 - 2)• repeat EUA/Debridement• definitive reconstruction
• Delayed (months to years)• settle in for the long haul• anticipate many operations• “fine tuning” of soft tissue envelope• don’t forget about psychiatry
Outline• Anatomy
• In the Field
• Acute Evaluation & Management
• Subacute/Long-term
Management
• Case Examples
Subacute/Long-Term
• Manage healing phase• Staged procedures• Wound complications• Trach/Peg weaning
• Begin rehabilitation phase
Subacute/Long-Term
• Plan additional procedures
• Manage psychiatric/psychological sequelae
• The underlying cause• The resultant issues
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Outline• Anatomy
• In the Field
• Acute Evaluation & Management
• Subacute/Long-term Management
• Case Examples
Case Examples
• #1 Self inflicted GSW
• #2 Shotgun Blast
• #3 Self inflicted GSW
• #4 Self inflicted GSW
Case Examples: Case #1
• 42 y/o woman self inflicted GSW
Case Examples: Case #1
Case Examples: Case #2
Case Examples: Case #3
• Self Inflicted GSW x 3– Emergent Craniectomy– Immediate Tracheostomy– Temporary ORIF Mandible to Hold Position– Ex-Fix after Osteo of Mandible– Congentially Absent Posterior Tibial aa bil
Case Examples: Case #3
Case Examples: Case #3
Case Examples: Case #3
Case Examples: Case #3
Case Examples: Case #3
Case Examples: Case #3
Case Examples: Case #4
• Self Inflicted GSW Submental– Military Rifle– Immediate Tracheostomy– Temporary Wire Mandible to Hold Position– Temporary Close Soft Tissue Envelope– Type I Diabetic
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Case Examples: Case #4
Conclusion
• Maxillofacial injury may be associated with life-threatening events• Airway• Bleeding• Associated Injuries
• Workup and timing impact outcome• Available resources and expertise
• These injuries often leave long-term sequelae in part due to disfigurement
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Questions?