Maxillofacial trauma requires careful assessment and management of the airway to prevent obstruction. The primary survey assesses and treats immediate life threats like airway, breathing, and hemorrhage. Airway management may require basic techniques like chin lift or advanced methods like endotracheal intubation. Bleeding is also a risk and can often be controlled through fracture reduction, packing, or embolization. Fluid resuscitation must balance preventing further blood loss with restoring perfusion.

2. Dr. Ahmed M. Adawy
Professor Emeritus, Dept. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University

3. Maxillofacial trauma is without doubt a most challenging
area within the specialty of oral and maxillofacial surgery.
As with all traumas, basic Advanced Trauma Life Support
principles (ATLS) should be applied to the initial
assessment of the casualty (1-3). Currently, ATLS has
become universally accepted as the gold standard in the
initial management of the multiply injured patients. The
system divides the initial assessment into a primary and
secondary survey. The primary survey aims to identify
immediate life-threatening injuries. The secondary survey
aims to identify all other injuries that will require
treatment but are not immediately life-threatening.

4. As part of the primary survey, a brief but detailed history
may be obtained, including the timing and mechanism of
the injury, and any previous treatment. The full extent of
some injuries may not be obvious during the initial
assessment; serial examinations may be necessary as
hemorrhage, swelling, or other bodily injuries are
identified. A more detailed examination may be performed
in a delayed setting. The examination should begin in a
systematic fashion; an overall inspection of the face will
reveal any asymmetry, contusions, swelling, or
hemorrhage. Frequently, asymmetry may be hidden due to
facial edema. Exposure is critical, so debris must be
cleared first. Palpation of the entire face will delineate any
step-offs or instability from the underlying skeleton.

5. Again, a top-down approach will make the examination
more efficient and focused. The practitioner should not be
distracted by the obvious injuries as this could mask less
obvious but more significant problems. Soft tissue injuries
should be noted, and any vital structures within range
tested; for example, a deep cheek laceration should prompt
a test for Stensen’s duct. Similarly, cranial nerves should
be examined for any deficits. Next, a complete ocular
examination should be given. Visual acuity, anterior
chamber inspection, visual field testing, pupillary reflexes,
light perception, and extraocular movements can be tested
quickly and efficiently.

6. If there is any concern for ocular injury, an ophthalmologic
consultation is recommended. The nose and septum should
be palpated and inspected for irregularity and signs of
fracture. The oral cavity should be inspected for
malocclusion, as well as any lacerations, foreign bodies, or
dentoalveolar damage. The mandible should be examined
and palpated for any step-offs or injury. Proper photo
documentation of current damage is key, as post-injury
states may be difficult to discern from postoperative
complications. Photographic consent should be obtained on
a routine basis (4).

7. Sensory and motor innervation to the face should be
evaluated. Paraesthesia after facial trauma is highly
suggestive of fracture due to injury or impingement of
trigeminal nerve branches. Mandible fractures can present
with loss of lip sensation due to injury to the inferior
alveolar nerve. Midface injuries may present with cheek
numbness due to injury to the infraorbital nerve. Injury to
the supraorbital and supratrochlear branches in the
forehead region may also occur. Facial nerve branches
palsy may result from penetrating injuries or superficial
lacerations as the nerve exits beneath the external auditory
meatus and divides within the substance of the parotid
gland (5).

8. The mnemonic for the primary survey is given by the
letters ABCDE.
• Airway maintenance with cervical spine protection.
• Breathing and ventilation.
• Circulation with hemorrhage control.
• Disability: neurological status.
• Exposure/environmental control - undress the patient but
prevent hypothermia.

9. The main cause of death in severe facial injury is airway
obstruction. According to Hutchison et al. (6), there are six
specific situations associated with maxillofacial trauma,
which can adversely affect the airway.
(1) Posteroinferior displacement of a fractured maxilla
parallel to the inclined plane of the base of the skull may
block the nasopharyngeal airway.
(2) A bilateral fracture of the anterior mandible may cause
the fractured symphysis and the tongue to slide posteriorly
and block the oropharynx in the supine patient.
(3) Fractured or exfoliated teeth, bone fragments, vomitus,
blood, and secretions as well as foreign bodies, such as
dentures, debris, and shrapnel, may block the airway
anywhere along the oropharynx and larynx.

10. (4) Hemorrhage from distinct vessels in open wounds or
severe nasal bleeding from complex blood supply of the
nose may also contribute to airway obstruction.
(5) Soft tissue swelling and edema which result from
trauma of the head and neck may cause delayed airway
compromise.
(6) Trauma of the larynx and trachea may cause swelling
and displacement of structures, such as the epiglottis,
arytenoid cartilages, and vocal cords, thereby increasing
the risk of cervical airway obstruction.
Airway management is commonly divided into two
categories: basic and advanced. Basic techniques are
generally non-invasive and do not require specialized
medical equipment or advanced training and can be
performed in pre-hospital setting.

11. Advanced techniques require specialized medical training
and equipment, and are further categorized anatomically
into supraglottic devices such as oropharyngeal and
nasopharyngeal airways, infraglottic techniques such as
tracheal intubation, and surgical methods such as
cricothyroidotomy, and tracheotomy.
The first action in the process of early airway management
is pre-oxygenation, which may prolong the time interval
up to hypoxemic state. However, mask ventilation is
problematical in the patient with maxillofacial trauma
because the oral cavity and/or oropharynx’s anatomy
could be disarranged by the trauma and/or blocked by
bleeding (7).

12. Bag valve mask ventilation.

13. In such condition, debris (broken teeth, dentures) is
removed from the mouth with a finger sweep. A Magill's
forceps may also be used for larger objects. Adequate
lighting and good suction are essential. The chin should be
pulled forward either through chin lift or jaw thrust
procedures. The jaw thrust and chin lift relieves soft tissue
obstruction by pulling the tongue, anterior neck tissues,
and epiglottis forward (8). In a bilateral fractured mandible,
pulling the anterior part of the mandible forward may clear
the airway. The recovery position is an important
preventive technique for an unconscious person. This
position entails having the person lie in a stable position
on their side with the head in a dependent position so
fluids do not drain down the airway, reducing the risk of
aspiration (9).

14. The head-tilt/ chin-lift is the most reliable method of
opening the airway, but should be used with extreme
caution in patients with suspected neck injuries.

15. Jaw thrust maneuver can open up the airway
with minimal spine manipulation.

16. The recovery position

17. Most airway maneuvers are associated with some
movement of the cervical spine. When there is a
possibility of cervical injury, collars are used to help hold
the head in-line. Maintenance of patent airway is usually
carried out by supraglottic devices. These devices ensure
patency of the upper respiratory tract without entry into
the trachea by bridging the oral and pharyngeal spaces (10).
An oropharyngeal airway is acceptable, however
nasopharyngeal airways should be avoided in trauma,
particularly if a basilar skull fracture is suspected (11).
Most commonly, patent airway could be maintained with a
combination of an oropharyngeal airway, suction, and jaw
thrust.

18. Oropharyngeal airways in a range of sizes

19. If the foreign body can not be removed quickly, it
should be left and a surgical airway performed. A
cricothyroidotomy is the preferred way to establish a
surgical airway in the emergency setting. A 5 or 6 mm
cuffed tracheostomy tube should be inserted through the
incision. Surgery is seldom necessary but should be
performed without delay when indicated. With trained
personnel, the procedure could be conducted safely with
minimal complications. The inability to secure or protect
the airway may lead to considerable morbidity and
mortality. In a study of 2594 trauma mortality patients,
Gruen et al. (12) found that failure to ventilate, secure or
protect the airway was the most common factor related to
patient mortality, responsible for 16% of inpatient deaths.

20. In cricothyroidotomy, the incision or puncture is made
through the cricothyroid membrane in-between the thyroid
cartilage and the cricoid cartilage

21. Cuffed tracheostomy tube

22. In hospital setting, decision is then made about the need
for a definitive airway intubation. Based on the conscious
level, severity of maxillofacial injury, risk of aspiration
(blood, vomitus etc.) and risk of obstruction secondary to
gross neck oedema, gross facial soft tissue swelling, or
concomitant laryngeal or tracheal injury, the need for
intubation is defined. The choice between oral and nasal
routes of intubation depends upon the surgical
requirements, the presence of associated nasal and base of
skull injuries. Nasotracheal tubes, however, should be
avoided in suspected or proven comminuted skull base
fractures due to the risk of displacement into the middle
cranial fossa (13). Fiberoptic guided intubation remains the
most reliable tool in accessing the difficult airway (14).

23. A cuffed endotracheal tube used in
tracheal intubation

24. Video-laryngoscope to intubate
the trachea

25. Hemorrhage is defined as an acute blood loss.
Hemorrhagic shock is associated with blood loss totaling
30% or more of total circulating blood volume.
Fortunately, life-threatening hemorrhage occurs in only
1% to 11% of patients with facial fractures (15). Delays in
management of hemorrhage may be because of time delay
in reaching the appropriate medical facility, unrecognized
bleeding, inadequate resuscitation, inability to control
hemorrhage by surgical means, and/or the presence of
inadequate clotting factors. The initial evaluation of the
trauma patient should be focused on arresting the
hemorrhage and establishing wide-bore intravenous
access.

26. In most cases, bleeding from the soft tissues of the head
and neck can be controlled by suturing or temporary
packing of the fracture site. Scalp lacerations may bleed
profusely but are unlikely to cause hypovolemic shock
with a reduction in blood pressure in an adult. However,
large scalp lacerations may be life threatening in children.
Any arterial source of bleeding in the scalp can be safely
clipped off and further hemostasis may be achieved with
packing, Raney clips, suturing or stapling (16). Intra oral
bleeding may be controlled by getting the patient to bite
on a swab. A conscious patient with maxillofacial injuries
is usually more comfortable sitting upright as this allows
blood and secretions to drain out of the mouth.

27. Raney clips

28. Bleeding from a tongue laceration can be torrential and
direct pressure may be not enough to control the bleeding;
in such cases deep sutures across the laceration are
advised to achieve hemostasis. Bleeding from fractured
mandible ends may be arrested by manually reducing the
fracture. In cases with a mobile maxilla the use of rubber
mouth gags is advisable. The mouth gags, which act as a
splint compressing the maxilla between the skull base and
the mandible, are placed between upper and lower
posterior teeth bilaterally. Following induction of
anaesthesia and intubation, manual reduction of facial
fractures can be carried out more readily and effectively if
not already accomplished.

29. There are various ways to temporarily stabilize facial
fractures, using wires, splints, or rapid intermaxillary
fixation. Extensive bleeding from the region of the
nasopharynx following trauma to the middle third of the
facial skeleton can be difficult to control. Epistaxis from
the nasal area can be either anterior or posterior. Profuse
anterior bleeding following trauma usually results from
laceration of the anterior ethmoidal artery and definitive
control usually requires nasal fracture reduction and firm
anterior packing. Posterior bleeding is usually associated
with laceration of the posterior ethmoidal artery and may
require anterior or posterior nasal packing. Double lumen
balloon catheters (epistat) with anterior and posterior
balloons can be very useful in these situations (17).

30. Epistaxis balloon catheter

31. Occasionally, if bleeding continues despite reduction of
facial fractures and packing, ligation of the external
carotid, internal maxillary, and ethmoidal arteries is
traditionally described. Due to the extent of most fractures
and extensive collateral supply, ligation may be necessary
on both sides (18). However, this is a complicated
technique and time-consuming procedure, with variable
success rates. In the presence of persistent hemorrhage,
despite appropriate interventions, it is important to
consider coagulation abnormalities, e.g. hemophilia,
chronic liver disease, and warfarin therapy. At all times the
cervical spine must be carefully immobilized.

32. Transcatheter arterial embolization (TAE) offers a safe
alternative to surgical ligation in life-threatening facial
hemorrhage. Catheter guided angiography is used to first
identify and then occlude the bleeding point or points.
Embolization involves the use of balloons, stents, coils or
chemicals (19). In experienced hands, the technique is
relatively quick. Further, multiple bleeding points can be
precisely identified and embolization of the bleeding
branches can arrest the hemorrhage (20). The technique
could be considered early in the course of management to
decrease mortality rate. Wu et al. (21) reported 7 cases
where angioembolization was successfully performed in
hemostasis of life-threatening maxillofacial trauma
hemorrhage.

33. A, Angiography shows left maxillary artery (large
arrow) and active contrast blush (small arrow).
B, No more contrast blush after coil embolization
(small arrow).

34. By the mean time, not only must bleeding be identified
and controlled as soon as possible, but concurrent
resuscitation must also be appropriate to each case.
Prolonged severe hypotension and associated tissue
hypoperfusion may result in secondary organ failure and
death at a later stage. The longer patients remain ischemic
from hypotension, the greater the likelihood of them
developing multi-organ failure. The statement ‘‘any cold
and tachycardic patient should be considered to be in
hypovolemic shock until proven otherwise’’ (2) is helpful.
Arterial blood gases are also particularly useful in the
early detection of hemorrhagic shock.

35. The main goals of management is to rapidly prevent
further blood loss and restore tissue perfusion as soon as
possible. The administration of intravenous isotonic fluids
in hypotensive trauma patients is currently one of the most
controversial issues in trauma. Sudden increases in the
blood pressure by massive doses of fluid transfusion may
precipitate re-bleeding. Another common dilemma is
which type of fluid should be given during resuscitation?.
For many years the choice has been between crystalloids
and colloids, but more recently there has been interest in
the use of hypertonic saline. However, its use remains
controversial, and a recent review of the evidence suggests
that there are insufficient data at present to justify routine
use in patients with severe head injury (22).

36. Within the last few years there has been a shift away from
aggressive fluid administration to accepting a lower blood
pressure, with greater emphasis on the immediate control
of bleeding. This approach came mainly as a result of the
Mattox trial in 1994, which showed significantly better
outcomes when fluids were withheld until bleeding was
controlled, rather than rapidly administered to patients
preoperatively (23). Although the optimal mean arterial
pressure has not yet been established, . It is now suggested
that the mean systolic blood pressure be kept at only 80
mmHg, in order to maintain adequate brain perfusion. In
an excellent review article Perry et al, (23) discussed in
depth the topic of hypovolemia and facial injuries in the
multiply injured patient.

37. Currently, the concept of ‘damage control’ has been well
accepted. Damage control has four phases.
1. Anticipation of ‘at-risk’ patients, based on the
mechanism of injury, and initial vital signs.
2. Damage-control procedures and surgery. These focus
only on controlling bleeding and preventing infection.
3. A period on ICU where the patient is fully resuscitated,
minimizing the biologic second hit.
4. A planned second procedure, where definitive repair of
all injuries is carried out.

38. Patients with traumatic injuries to the head are at high risk
of cervical spine injury. A patient with a supraclavicular
injury is considered to have a C-spine injury. Successful
diagnosis of cervical spine injury associated with
maxillofacial trauma requires a high index of suspicion in
all cases besides a thorough clinical and radiological
examination. Until the C-spine is cleared radiologically
and clinically, precautions must be made during the
perioperative period. The patient must be fitted with a
neck collar for cervical spine immobilization. This is
especially important during transport and positioning for
surgery.

39. Neck collar for cervical spine immobilization

40. Injuries to the midface are most commonly associated
with C5-7 disruption (the most mobile part of the cervical
spine), while injuries to the lower face tend to be
associated with C1-4 disruption. The incidence of cervical
spine injury associated with maxillofacial trauma varies in
the literature from 0.3% to19.3% (24). Facial injuries
associated with motor vehicle accidents are more
frequently associated with cervical spine injuries than
those caused by falls or assaults. The current
recommendation is for radiological examination of the
cervical spine in every unconscious patient suffering from
maxillofacial trauma.

41. MRI of fractured and dislocated neck vertebra
compressing the spinal cord

42. Any patient with maxillofacial injury irrespective of
whether it is associated with fractures or not is always at
risk of traumatic brain injury. Hence, all the patients with
maxillofacial injuries should be under neurosurgical
observation and regular follow up. Further, patients with
maxillofacial fractures due to trauma have a higher risk of
intracranial hemorrhage when compared to those without
maxillofacial fractures. Haug et al (25), reported that 17.5%
patients with facial fractures had some form of closed
head injury whereas almost 10% sustained a severe
intracranial injury. Early diagnosis of traumatic brain
injury leads to prompt treatment which is essential to
improve the outcome of these patients. In head injury
patients, CT is the imaging modality of choice.

43. The predictors of intracranial hemorrhage include
vomiting/ nausea, skull fractures, seizures and C-spine
injury. Among these C-spine injury is the best predictor of
intra cranial hemorrhage. Vomiting is linked with a 25%
higher risk of intracranial hemorrhage and seizures are
linked with a 15% higher risk of intracranial hemorrhage
(26). If a cerebrospinal fluid (CSF) leak is suspected,
neurosurgical advice sought and antibiotic prophylaxis
considered. CSF leak can happen because of trauma to
ethmoid and its cribriform plate, frontal sinus, anterior
skull base and orbital roof. Most of the times the patient
presents with features like rhinorrhea, otorrhoea,
headache, decreased hearing sensation and a salty taste.

44. Otorrhoea
Rhinorrhea

45. Usually conscious patients with a Glasgow Coma Scale
(GCS) score of 15 with no clinical neurological
abnormalities are not expected to have an intracranial
pathology. However, high velocity impact can result in
intracranial hemorrhage. 2.8% of neurologically “normal”
patients suffer from intracranial hematomas (26). Hence
intracranial hemorrhage cannot be excluded in these
patients. The use of the Glasgow Coma Scale (27) became
widespread in the 1980s when the first edition of the
Advanced Trauma and Life Support recommended its use
in all trauma patients.

46. The scale is used to objectively describe the extent of
impaired consciousness level according to three aspects of
responsiveness: eye-opening, motor, and verbal responses.
Reporting each of these separately provides a clear,
communicable picture of a patient’s state. Head injury is
considered severe if a Glasgow coma scores is less than or
equal 8. The head injury is considered as moderate, if a
Glasgow coma score is 9 to 12, and in Glasgow coma
scores of 13 to 15, the head injury is considered as minor.
However, the GCS requires observation of eye-opening,
motor and verbal score which is often unavailable in
intubated patients, brain steam injuries, and occular
trauma. Also, it must be interpreted in cases of concurrent
sedation. Further is the interpersonal variability in
assessment of the scores.

47. Glasgow Coma Scale

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