International Journal of Oral and Maxillofacial Surgery
Invited Review Paper
TraumaAdvanced Trauma Life Support (ATLS) and facial trauma: can one size fit all?: Part 1: Dilemmas in the management of the multiply injured patient with coexisting facial injuries
Trauma
Section snippets
ATLS – the gold standard
Since its inception in 1978, the Advanced Trauma Life Support (ATLS)3, 17, 67 system of care has generally become accepted as the gold standard in the initial management of the multiply injured patient and is now taught in over 40 countries worldwide. This approach is based on the three well established principles of:
- 1.
ABCDEs of assessment (Airway maintenance with cervical spine protection, Breathing with ventilation, Circulation with haemorrhage control, Disability; neurological status, and E
Establishing priorities
During the initial assessment of trauma victim patients a systematic approach should ensure that life-threatening and subsequent injuries are identified and then managed in a timely manner. Unfortunately this may not be as simple as we would like.
- 1.
Priorities can conflict. The ‘ABCDE’ approach during the rapid primary survey3 is designed to recognise and simultaneously manage life-threatening problems in the order that they will most likely kill the patient – ‘Treat the greatest threat to life
Triaging facial injuries
From a practical point of view, maxillofacial injuries can be broadly placed into one of four groups based on the urgency of treatment required.
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Immediate treatment: interventions are either resuscitative or emergent (life or sight preserving), although not necessarily definitive (e.g. surgical airway, control of profuse haemorrhage, lateral canthotomy and cantholysis).
- 2.
Treatment within a few hours: interventions for clinically ‘urgent’ conditions (e.g. heavily contaminated wounds and some open
Conflicts of interest
The last 20 years or so have seen major changes in how we manage trauma patients23. In some areas long-standing practices are being challenged6, 9.
In the general trauma literature, we have seen the development of ATLS, trauma teams and prehospital care, all of which have undoubtedly improved quality of care and patient survival. More recently, there has been a lot of debate on whether we should carry out ‘early total care’50 (i.e. once resuscitated, take the patient immediately to theatre from
Mechanism of injury
Knowledge of the mechanism of injury is a vital component in the assessment of the injured patient12, 59 as it can give us useful clues to the possibility of associated and sometimes occult injuries21, 31, 33, 44, 48, 54, 70. This is particularly important in maxillofacial trauma, as we may be asked to accept patients under our care, perhaps requiring inter-hospital transfer, because their only obvious injury is to their face. It is worth remembering that approximately 15% of all injuries
Early maxillofacial involvement in polytrauma
Maxillofacial surgeons should be an integral part of the trauma team for those patients where facial injuries are evident. This involvement is particularly relevant during the management of:
- 1.
the airway,
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hypovolaemia including facial bleeding and
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craniofacial injuries, and
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in the assessment of the eyes.
This input is just as relevant with what may initially appear to be minor facial injuries. During and immediately after the ‘golden hour’, maxillofacial surgeons may need to provide an advisory
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General Overview of the Facial Trauma Evaluation
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