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Premium member Presentation Transcript Maxillofacial Trauma: Maxillofacial Trauma Le Fort facial fractures Determined common fracture lines of maxilla and face by cadaver experimentation in 1901 Divided into Le Fort I, II, and III fracture Basal skull fracture should ALWAYS be considered a possibility in presence of severe midfacial traumaPowerPoint Presentation: Figure 15. Drawings show the common Le Fort fracture patterns Hopper R A et al. Radiographics 2006;26:783-793 ©2006 by Radiological Society of North AmericaLe Fort I Fracture: Le Fort I Fracture Also known as Guerin or transverse maxillary fracture Dental-alveolar fracture of maxilla, passing above floor of nose, hard palate Involves Lower third of nasal septum Mobilizing palate, maxillary alveolar process, lower third of pterygoid plates, and part of palatine boneLe Fort I Fracture: Le Fort I Fracture Can be displaced laterally or posteriorly, rotated on an axis, or a combination Little airway compromise Can be intubated orally or nasallyLe Fort II fracture: Le Fort II fracture Also known as pyramidal fracture of maxilla Involves Thick upper part of nasal bone Thinner portion forming upper margin of anterior nasal aperture Triangular fracture Crosses medial/inferior wall of orbit, including lacrimal bone, runs underneath zygomaticomaxillary suture, crosses lateral wall of maxilla (antrum), then continues posteriorly through pytergoid platesLe Fort II Fracture: Le Fort II Fracture Can be displaced posteriorly or rotated on an axis Nasal intubation relatively contrainindicated because of fractured nose Could introduce ETT, foreign material, air into skull Meningitis Brain injuryLe Fort III Fracture: Le Fort III Fracture Also known as craniofacial disjunction Fracture line runs parallel to skull base Separates midfacial skeleton from cranial base Zygomatic arch of temporal bone fractured Extends through nose base, ethmoid bone, eye orbits, sphenopalatine fossa in depth Cribiform plate of ethmoid may be fractured disrupting integrity of base of skull and opening into subarachnoid spaceLe Fort III Fracture: Le Fort III Fracture Mid face separated from cranial skeleton Displaced posteriorly characteristic “dish face deformity” Awake tracheostomy usually used to secure airway Obviates risk of intubation Operative field free for surgeonAirway management with Le Fort II and III fractures: Airway management with Le Fort II and III fractures Disruption of cribiform plate may open underside of cranial cavity Inadvertent intracranial placement Signs and symptoms to watch out for: Presence of cerebrospinal fluid in nose Blood behind tympanic membrane Periorbital edema “ Raccoon eyes” hematomaOrthognathic procedure considerations: Orthognathic procedure considerations Often require splitting the mandible to move lower jaw forward or back Osteotomies Extensive blood loss T & C Hypotensive anesthesia External or internal fixation devices to stabilize mandible Cutting tools MUST be with patient at ALL times Consider fixation and edema issues when planning extubationMandibular Trauma: Mandibular Trauma Mobility limited due to: Trismus Edema Pain Mechanical disruption Condyle fracture Zygomatic arch of temporal bone fracture Zygoma fractureMandibular fracture: Mandibular fracture High speed, high impact trauma (MVC) Fractures of ramus, condyle, angle of mandible Low speed, low impact trauma (fist fight or fall) Fractures within body of mandible, symphysis, parasymphyseal region Site of fracture often determines extent of airway compromise Edema Blood/secretions Mobility issues True emergency: grasp midline mandible and pull forward reducing fractureSpinal cord injury: Spinal cord injury High index of suspicion related to mechanism of injury Always treat as suspected C-spine injury unless proven otherwise C collar Inline stabilization with intubation RSI/airway adjunctsSCI: SCI Leading cause of death at scene: aspiration Most injuries occur in males in 20’s-30’s Occur from falls, MVC’s, diving injuries, penetrating missiles, sports injuries Must obtain lateral C-spine X-ray C7 most common site of injurySigns and symptoms related to SCI: Signs and symptoms related to SCI Paralysis Pain Position: “Hangman position”: patient holding head upright with both hands may indicate Jefferson fracture C1 “Hold-up position” : arms above head may indicate C4-5 fracture “Prayer position”: arms folded across chest possible C5-6 fractureS/S of SCI cont’d: S/S of SCI cont’d Paresthesias Ptosis PriapismAnesthetic management with SCI: Anesthetic management with SCI Nasal intubation method of choice if patient does not have associated basilar skull fracture/LeFort 2-3 fractures Topical anesthesia Avoid transtracheal block due to increased risk of aspiration and movement of neck with coughing Oral intubation: induce patient then remove front of C collar and hold in-line stabilization/RSIMuscle relaxants with SCI: Muscle relaxants with SCI Succinylcholine: do not give to patients > 24 hours post massive muscle or denervation injuries, SCI’s, crush injuries or burns Acutely may want to avoid secondary to fasciculation's that may exacerbate SCI Can give curarizing dose of NDMR High dose Vec or Roc good alternativeAnesthetic management with SCI: Anesthetic management with SCI High dose steroids: marginal benefit with substantial long-term complications Deliberate hypothermia: still investigational; complicated by shivering, coagulopathy, infectionSpinal shock: Spinal shock Hypotension Bradycardia Hypothermia/poikilothermia (body temperature migrates toward environmental level) Results from sympathectomy in SCI patients More intensified at T6 level and higherSpinal shock: Spinal shock Patients present with hypotension, bradycardia and warm, pink extremities Hemmorrhagic shock tend to be hypotensive, tachycardiac with cold, clammy skin Treatment: Careful volume resuscitation Unable to maintain adequate cardiac filling pressures but overaggressive fluid administration can precipitate pulmonary edema (neurogenic)Spinal shock cont’d: Spinal shock cont’d May require pressors Dopamine 4-5 mcg/kg/min Avoid using radial arteries for arterial line if paraplegic If arm embolizes, patient at severe disadvantageAutonomic hypereflexia: Autonomic hypereflexia Occurs after spinal shock passed >24 hours post injury + patients return to OR for subsequent operations stimulation below level of lesion Seen in 85% of patients with injuries above T5Autonomic Hypereflexia: Autonomic Hypereflexia S/S Hypertension Bradycardia Dysrhythmias Cutaneous vasodilatation above , vasoconstriction below injury Severe headaches Seizures Loss of consciousness Treatment: stop stimulus; deepen anesthesia; CV supportSummary: Summary Risk/benefit assessment of: RSI Value of aggressive fluid resuscitation Role of hyperventilation in TBI Future treatments: Growing noninvasive diagnostic technologies Increased control and development of blood and coagulation products Patient-specific anti-inflammatory therapiesAny Questions?: Any Questions? 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