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The systematic assessment of patients with facial injuries is the culmination of wisdom from trials and errors, audits of failures and successes, careful and mindful reflection of current practice, and a willingness to change.
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Emerging technology has positively impacted the practice of management of facial trauma.
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A systematic evaluation and physical examination of the trauma victim remain the gold standard and the first step toward effective care.
Oral and Maxillofacial Surgery Clinics of North America
Systematic Assessment of the Patient with Facial Trauma
Section snippets
Key points
Traumatic injuries affect thousands of
Assessment principles in trauma
The principles in systematic assessment of the trauma patients as outlined by the ATLS protocols are as follows1:
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Preparation and transport
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Triage
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Primary survey (ABCDEs)
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Resuscitation
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Adjuncts to primary survey and resuscitation including monitoring and radiography
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Consideration for the need for patient transfer
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Secondary survey—head-to-toe evaluation, patient history
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Adjuncts to secondary survey—special investigations, such as computed tomographic (CT) scanning or angiography
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Continued
Airway with cervical spine protection
Penetrating neck trauma, complex multiple facial soft tissue, and bony injuries of the maxillofacial skeleton necessitate immediate intervention to protect the anatomic airway. Foreign bodies, gastric content regurgitation, and tracheal or laryngeal fractures may not be dramatically apparent. Whenever possible, an endotracheal intubation is preferred and attempted and a surgical airway is sought only when the endotracheal intubation is not practical or possible.
Bilateral mandibular body or
Breathing and ventilation
ATLS suggests exposure of the neck and chest and ensuring immobilization of the head and neck. Tracheal deviation, signs of airway obstruction, and subtle signs such as cyanosis of the lips suggestive of hypoperfusion are not to be missed. Transient brain hypoxia can cause severe secondary brain injury. Simple maneuvers such as stabilizing the mandible can improve breathing and ventilation, preventing long-term hypoxia-related neuro-deficits.
Circulation with hemorrhage control
As in primary survey for polysystem trauma, circulation is a priority only following stabilization of airway and ensuring breathing and ventilation.
Structures of the head and neck are extremely vascular and can often cause significant extravasation of blood that can contribute to shock. An assessment for bleeding should be systematic, complete, and thorough, addressing all evident and occult bleeding from vessels of the maxillofacial region.
Occult bleeding could occur acutely or in a chronic
Disability (neurologic and functional evaluation)
During the primary survey, a Glasgow Coma Scale establishes a baseline neurologic status for the patient. During the secondary survey and later, this is reassessed constantly using a simple AVPU method:
A—Patient is awake, alert, and appropriate
V—Patient responds to voice
P—Patient responds to pain
U—Patient is unresponsive
Pupillary examination is a quick assessment of the cerebral function. Any changes in pupillary response indicates cerebral damage, optic nerve damage, or changes in intracranial
Exposure
Patients that present with a helmet (sports-related or motorcycle-related) should have the helmet removed while the head and neck are held in a neutral position using a 2-person technique. The American College of Surgeons provides a poster entitled, “Techniques of Helmet Removal from Injured Patients” (www.facs.org/trauma/publications/helmet.pdf).
Dentures and other removable appliances that may not have caught the attention of the resuscitating team may become evident on secondary survey by the
Systematic clinical examination of the facial trauma patient
To minimize not finding injuries, and optimizing the assessment in a busy trauma bay, a systematic assessment pattern is recommended in examining patients with facial trauma. It is best to examine every patient the same way every time and record the findings comprehensively every time to ensure a thorough examination.
For purposes of the physical examination, the face and neck are divided into different zones and structures in each zone will be inspected and palpated and then correlated with
Summary
The systematic assessment of the patient with facial injuries as practiced today is the culmination of the collective wisdom from trials and errors, audits of failures and successes, careful and mindful reflection of current practice, and a willingness to change. Emerging technology has positively impacted the practice of management of facial trauma. Regardless, a systematic evaluation and physical examination of the trauma victim remain the gold standard and the first step toward effective
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Cited by (0)
Disclosures: The author has nothing to disclose.