Invited Review Paper
Trauma
Advanced 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

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Abstract

Maxillofacial trauma is without doubt still a very challenging area, especially in the early stages of care when other injuries may be present. Craniofacial trauma, with or without life and/or sight-threatening complications, may be associated with significant injuries elsewhere. Both general trauma and facial trauma management have evolved considerably over the last 20 years and on occasion clinical priorities may seemingly conflict, suddenly change or be hidden. In these circumstances a number of clinical dilemmas may arise, which this and three further reviews will discuss. These are based on review of the current literature, supplemented where appropriate by the collective experiences of the co-authors. Facial injuries can be broadly placed into one of four groups, which can aid determination of the urgency for treatment. Advanced Trauma Life Support is generally regarded as the gold standard and is founded on a number of well known principles, but strict adherence to protocols may have its drawbacks when facial trauma co-exists. These can arise in the presence of either major or minor facial injuries, and oral and maxillofacial surgeons need to be aware of the potential problems.

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.

  • 1.

    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,

  • 2.

    hypovolaemia including facial bleeding and

  • 3.

    craniofacial injuries, and

  • 4.

    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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