TRAUMA—-DANIEL W TODD, MD
OTOLARYNGOLOGY TRAUMA DATA BASE—–DANIEL W TODD, MD
MECHANISM OF INJURY:
DO YOU HAVE A HISTORY OF:
___HIGH BLOOD PRESSURE
___DIABETES
___HEART DISEASE
___LUNG DISEASE (ASTHMA, EMPHYSEMA)
___BLEEDING DISORDERS
PREVIOUS SURGERIES AND DATES:
MEDICATIONS AND DOSAGES:
MEDICATION ALLERGIES AND REACTION:
HAVE YOU RECENTLY USED:
___ALCOHOL
___TOBACCO
REVIEW OF SYSTEMS:
DO YOU HAVE ANY RECENT:
___SIGNIFICANT WEIGHT LOSS
___FEVERS OR CHILLS
___CHEST PAIN
___SHORTNESS OF BREATH
___NAUSEA/VOMITING/DIARHEA
___BLOOD IN STOOL OR URINE
___DIFFICULTY OR PAIN SWOLLOWING
___SKIN CHANGES OR PROBLEMS
___PREGNANCY OR NURSING
PHYSICAL EXAM:
VITAL SIGNS:
GENERAL APPEARANCE:
Well developed yes/no If no, explain:
Deformities no/yes If yes, explain:
Ability to communicate norm/abnl If abnl, explain:
Quality of voice norm/abnl If abnl, explain:
PERRL/EOM norm/abnl If abnl, explain:
HEAD AND FACE:
Overall appearance norm/abnl If abnl, explain:
Scars or lesions no/yes If yes, explain:
Frontal bone norm/abnl If abnl, explain:
Nasal bones norm/abnl If abnl, explain:
Zygomas norm/abnl If abnl, explain:
Maxilla stable/unstable—LeFort ( )
Mandible stable/unstable
Occlusion class I/other
Trigeminal Nerve norm/abnl If abnl, explain:
Facial Nerve norm/abnl If abnl, explain:
EARS, NOSE, MOUTH, AND THROAT
External ear and canals norm/abnl If abnl, explain:
Hemotympanum? no/yes If yes, explain:
Septal Hematoma no/yes If yes, explain:
Lips, Teeth, and Gums norm/abnl If abnl, explain:
Oropharynx norm/abnl If abnl, explain:
NECK
Neck masses, appearance norm/abnl If abnl, explain:
Larynx: norm/stridor/eccymosis/S.Q. emphysema
Thyroid norm/abnl If abnl, explain:
RESPIRATORY
Respiratory effort norm/abnl If abnl, explain:
Auscultation norm/abnl If abnl, explain:
CARDIOVASCULAR
Heart Sounds norm/abnl If abnl, explain:
LYMPHATIC
Peripheral Edema norm/abnl If abnl, explain:
NEURO/PSYCH
Mood and Psych norm/abnl If abnl, explain:
DOC BAG
EPI
BENZO
LOCAL
SUTURE, NEEDLE DRIVER, PICKUPS
KNIFE, CRIC TUBE
STEROID
NITRO?
ANTIHISTAMINE (TYPE 1 AND 2)
MSO4
BANDAGES/WRAPS
INITIAL SURVEY—60 SECONDS
A, B, C—S (SPINE)
LESS THAN 8 DO A NEEDLE CRIC—-14 GUAGE NEEDLE—HOOK INTO A JET VENT OR A 1 PRONG OF NCO2 AT 10 LITERS
DO STERNAL COMPRESSIONS 2 TIMES EVERY MINUTE TO HELP BLOW OFF CO2
INTUBATE—AGE/4 + 4 = ETT SIZE (OR SIZE OF CHILDS PINKEY FINGER)
S.C.I.W.O.R.A. (SPINAL CORD INJURY WITHOUT RADIOGRAPHIC ABNL)
MUST HAVE BOTH RADIOGRAPHIC AND CLINICAL SPINE CLEARANCE—CHILDREN GO HIGH (C1-2) ADULTS LOW (C5-7)
FACIAL FRACTURES AND APNEA ARE CONTRAINDICATIONS TO BLIND NASAL INTUBATION
3 PLAIN FILMS—CXR, C-SPINE AND PELVIS
ALWAYS DO A THOUROUGH EXAM IMMEDIATELY—-TEST AND DODCUMENT ALL CN=S
ABNL NEURO EXAM—-OUT OF PROPORTION—THINK OF DIFFUSE AXONAL SHEARING VS CAROTID INTIMAL FLAPS (MAY WANT TO DO A SPIRAL CT SCAN WITH CONTRAST.
MRI FOR TRAUMA IS RARE—T1 BETTER FOR ANATOMY(FAT =BRIGHT), T2 (H20=BRIGHT) IS BETTER FOR PATHOLOGY
GCS—E (4), M (6), V (5)—GET THE MOST (6) FOR MOTOR, THE LEAST FOR EYE OPENING
LR IS BEST FOR POST TRAUMATIC REHYDRATION—-130 MEQ OF NACL—-VS NS (154)—-LEAD TO HYPERCHLOREMIC METABOLIC ACIDOSIS
BOLUS CHILD 20CC/KG LR—REPEAT X 1 THEN BLOOD AT 10CC/KG UNTIL BP REASONABLE
BLEEDING IS THE PRIMARY CAUSE OF POST TRAUMATIC HYPOTN—(FLAT NECK VEINS)
TENSION PNEUMO OR TAMPANADE—-DISTENDED NECK VEINS—NEEDLE THE 2-3RD INTERCOSTAL SPACE ON THE ANT CHEST
ANY OPHTH QUESTIONS—-REFER—ABNL IN THE SHAPE OF THE IRIS COULD BE INDICATIVE OF A GLOBE RUPTURE
MANAGE TRAUMATIC TATOOS AND ROAD RASH EARLY WITH MANUAL EXTRACTION AND DERMABRASION
BURNS/CAUSTIC INGESTION
REALLY 2 TYPES OF INSULTS—-KIDS (SMALL QUANTITY) MUCH LESS OF AN ENTITY SINCE CHEVALEIR JACKSON FAMILIARIZED THE NATION WITH SAFETY RECS—AND ADULTS (MASSIVE SUICIDAL QUANTITY)
2 GOALS OF THE PRACTITIONER—DONT GET BLAMED FOR THE SHORT TERM DISASTERS AND MINIMIZE THE LONG TERM COMPLICATIONS
Hx
EXACT TYPE AND QUANTITY OF THE INGESTION -SEND PARENTS HOME TO GET THE PACKAGING
CALL POISON CONTROL
BASE (WORSE)–LIQUIFACTION NECROSIS (BLEECH, LYE—DRANO, AMONIA, ELECTRIC DISHWASHER SOAP, HAIR RELAXER)—-ALSO DISK BATTERIES—BEGIN TO EVOKE DAMAGE IN HOURS
ACID––COAGULATION NECROSIS
PE
ALWAYS EXAMINE THE PT THOUROUGHLY—–NOTE APPEARANC OF OC AND OP–
MAY HAVE MAX SWELLING AND REQUIRE INTUBATION FROM 1-5 HOURS
NOTE DROOLING, ODYNOPOHAGIA, CHEST PAIN, ACUTE ABDOMEN
MAY TRY FLEXIBLE EXAM OF AIRWAY AND HP
20% WITH NO OC BURN WILL HAVE ESOPHAGEAL BURNS
BARIUM STUDY WILL SHOW ATONIC DILATED ESOPHAGUS—NOT INDICATED EARLY
esophagoscopy within 24- 48 hours
(TODAYS BLEACHES NOT MORE THAN 6% SODIUM HYPOCHLORITE—–PROBABLY DO NOT REQUIRE ENDOSCOPY))
Rx: ADMIT, NPO, CXR, IVF, steroids, IV ABX, IV ANTACIDS
MANAGE EXPECTANTLY IF INSULT MORE THAN 48 HOURS AGO
TOPICAL ANTIBIOTICS A GOOD IDEA (P.O. AMOXACILLIN)
IRRIGATE OC AND OP WITH LARGE AMOUNTS OF WATER —MAY DRINK MILK OF WATER FREELY—DO NOT INDUCE VOMITING
USING AN ACID SUCH AS CITRUS JUICE TO NEUTRALIZE A BASE CREATES AN EXOTHERMIC RXN—-PROBABLY NOT DANGEROUS BUT NOT ADVOCATED
REMOVE ALL CLOTHES WHICH ARE CONTAMINATED
ESOPHAGOSCOPY—-@ALL CAUSTIC INGESTIONS GET SCOPED@—-UNLESS—LESS THAN 1 HOUR POST INGESTION, MORE THAN 48 HOURS POST INGESTION, KNOWN AGENT WHICH ISN=T SO CAUSTIC (BLEACH), PTS WHO HAVE BEEN ON HIGH DOSES OF STEROIDS, AND SEVERE HP OR SUPRAGLOTTIC BURNS
FLEXIBLE VS RIDGID?
IF LESS THAN 1 HOUR—ERYTHEMA—-NOT VERY TELLING
> 1 HOUR—SEE SHAGGY AREA–BURN—-STOP WHEN YOU SEE THE 1ST BURN— IMMEDIATELY PLACE NG TUBE?—-PROBABLY A GOOD IDEA
ABX (CLEOCIN 25 MG/KG/DAY), STEROIDS(PREDNISONE 2MG/KG/DAY)—PROBABLY HELP PREVENT STRICTURE FORMATION—ALSO MAY MASK PERFERATION CLINICALLY (HPD AND TEMP), ANTACIDS(PROTON PUMP INHIBITOR) AND NPO—-PRAY—-PROBABLY–USE TPN–AVOID ANY ENTERAL STIMULATION (REST THE GUT)—FREELY CONSULT MANY EXPERTS—SHARE THE BLAME
CONSIDER SURGICEL ON RAW SURFACES AND CARAFATE AS AN IONIC DSG—ALONG WITH TOPICAL ANTIBIOTICS
ALL VERY CONTROVERSIAL—-SOME LITERATURE ADVOCATES ENDOSCOPY ON ONLY SYMPTOMATIC INDIVIDUALS
AIRWAY IS YOUR BIGGEST CONCERN
RESULTS:
Negative – FU in 2 weeks if asymptomatic
Barium swallow if symptomatic
Positive—-PHOTODOCUMENT TO SHOW CONSULTANTS
Do not proceed past point of burn, IMMEDIATELY INSTITUTE abx, steroids
NG controversial < 24 hours /direct visualization
Weakest point IS at 5 – 8 days
Scar at 6 weeks
REPEAT ESOPHOGRAM Q 3 WEEKS
IF PRESENT AFTER 48 HOURS—CXR AND BARIUM ESOPHAGRAM
MAY NEED DILATIONS—-NO STEROIDS
AS A RULE WOULD ADMIT—-CONSULT, NPO, TPN, NG TUBE, STEROIDS, IV ANTACIDS, CARAFATE–SCHEDULE FOR ENDOSCOPY IN 24-36 HOURS—DON=T BE A COWBOY AND DISCHARGE THEM UNTIL YOU ARE SURE THEY ARE OUT OF THE WOODS!
FACIAL BURNS
> 20% BSA IN ADULTS OR > 15% IN CHILDREN IS GOING TO CAUSE SIG THIRD SPACING AND AGGRESSIVE REHYDRATIUON AND FLUID AND ACID- BASE MONITORING IS INDICATED
GET A BASELINE ABG, CARBOXYHEMAGLOBIN LEVEL, BODY WIEGHT, CBC, LYTES (RENAL PANEL), UA, CXR—-THINK ABOUT A XENON-133 PULM PERFUSION SCAN TO ASSESS INJURY
EXAMINE OC/OP FOR CARBINACEOUS DEBRIS EXT…MAY DO A FLEXIBLE EXAM
PROBABLY A GOOD IDEA IF YOU ARE WORRIED TO GO TO THE O.R AND DO A DL OND FLEXIBLE BRONCHOSCOPY—-BE READY TO DO A TRACH!
CONSIDER ABX AND DECADRON—I WOULD USE THEM!
IF YOU ARE NOT GOING TO SECURE AN AIRWAY—PUT THEM IN THE UNIT ON 100% O2
GET SERIAL ABG=S, CXR=S AND CARBOXYHEMAGLOBIN LEVELS
SMOKE INHALATION
ERYTHEMATOUS LIPS AND CARBINACEOUS DEBRIS AND DISCOLORING NASAL VESTIBULE AND O.C.
DRAW BLOOD FOR LEVELS—PUT ON 100% O2 BY A NON RE-BREATHER ?HBO?
GENTLE CLEANSING AND DEBRIDEMENT WITH A NONALCOHOL SOAP IS IN ORDER (TID)
PAIN CONTROL AND SILVIDENE
SYSTEMIC ABX AND STEROIDS AND TETANUS PROPHYLAXIS IS IN ORDER
EARLY INTERVENTION ON EYLID RECONSTRUCTION FOR BOTH FUNCTIONAL AND COSMETIC REASONS
ORAL SPLINTS AND NASAL STENTS TO PREVENT STENOSIS
MULTIDISCIPLINARY APPROACH TO REHAB—CONSIDER CONSULTING—A LOSER=S GAME
PEDS PENETRATING PHARYNGEAL TRUAMA
A COMMON PRESENTATION IS THE F.B. IMPALING THE SOFT PALATE
AN AREA FILLED WITH CONTROVERSY
SECURE AN AIRWAY IN THE O.R.
GET IV ACCESS AND LABS—-HB, LYTES, BARIUM SWALLOW, ARTERIOGRAM VS COLOR FLOW DUPLEX ULTRASONOGRAPHY
IF THE OBJECT STILL IN WATCH IT FOR PULSATIONS—-TRY TO SEE IT WITH AN ENDOSCOPE IN THE NP
REMOVE IT CAREFULLY AND EXPLORE THE TRACT BLUNTLY WITH A HEMOSTAT
NEED TO BE AWARE OF DELAYED NEURO PROBLEMS FROM INTIMAL (ENDOTHELIAL) DAMAGE
NEED FOR ANGIOGRAPHY AND OR ANTICOAGULATION IS VERY CONTROVERSIAL
NECK TRAUMA
5-10% OF ALL TRAUMA
THE LEADING CAUSE OF DEATH IS HEMORRAGE
BLUNT TRAUMA
PENETRATING TRAUMA
HIGH VELOCITY (> 610 M/SEC)—RIFLES—–VS LOW VELOCITY (<610M/SEC)–HANDGUNS, SHOTGUNS, STABBING
DIFFERENTIATE THE MECHANISM AND VELOCITY—OVER VS UNDERHAND
SELLETA AND MONSON AGREE—-ZONE 3 ABOVE THE INF BORDER OF THE MANDIBLE
SELLETA—ZONE I —INF THE THE STERNAL NOTCH
MONSON—-ZONE I—INF TO THE CRICOID—–IN ANY CASE PROBABLY NOT AMENABLE TO EASY EXPLORATION
ANGIOGRAPHY AND BARIUM SWALLOW FOR ZONE I AND III (SERIAL INTRAORAL EXAMS)
ZONE II NECK EXPLORATION (IF PENETRATES THE PLATYSMA) VS SERIAL EXAMS AND RADIOGRAPHIC ANALYSIS
NEW STUDIES DEMONSTRATE THAT IN THE ABSENSE OF CLINICAL SIGNS—ARTERIOGRAPHY YIELDS LESS THAN 1-2%. COLOR FOW DUPLEX ULTRASONOGRAPHY MAY BE NEARLY AS SENSITIVE WITH LESS INVASIVENESS
“YOU KNOW WHEN YOU ARE GOING TO NEED TO OPERATE”
ALWAYS ASSUME A C-SPINE INJURY
NEURO EXAM—-APPROX 30% ASSOC WITH CAROTID INJURY
LISTEN FOR BRUITS
CXR–R/O PNEUMO
SQ EMPHYSEMA
GASTROGRAFFIN OR BARIUM SWALLOW
IF YOU DO AN EXPLORATION—DO A DL
GET IV ACCESS AND LABS—-HB, LYTES, BARIUM SWALLOW, ARTERIOGRAM VS COLOR FLOW DUPLEX ULTRASONOGRAPHY
PHARYNGEAL/ESOPHAGEAL TEAR—-2 LAYER CLOSURE–MUSCLE FLAP–?CLOSE SKIN OVER A DRAIN
LARYNGEAL TRAUMA
Hx—–AGAIN ALWAYS ASSUME A C-SPINE INJURY!
THERE IS A FORMAL GRADING SCALE FOR LARYNGEAL INJURIES—-ACEDEMIC
S.Q. EMPHYSEMA
HOARSENESS—APHONIA
LOSS OF PALPABLE PROMINENCE
HEMOPTYSIS
ECCYMOSIS
AIR OR SALIVARY LEAK FROM PENETRATING WOUND
GET FLEXIBLE SCOPE
BLOOD—EXPOSED CARTILAGE—SUBMUCOSAL HEMATOMA/ECCYMOSIS
TRAUMATIC ARYTENOID DISLOCATION
MAXIMAL SWELLING IS PROBABLY IN 5-6 HOURS
RARE BUT LEATHAL—1/30,000 ER VISITS—–HIGH ASSOC WITH OTHER INJURIES—ESOPHAGEAL AND C-SPINE, FACIAL AND CHI
WHEN IN DOUBT—-TRACH—–DO PAN ENDOSCOPY
IF QUESTIONABLE Dx—–GET CT SCAN
REPAIR MUCOSAL LACS WITHIN 24 HOURS (DELAY RAISES RISK OF STENOSIS)—PROBABLY VIA LARYNGOFISSURE APPROACH WITH A KEEL
DISPLACED FxS NEED REDUCTION (TIMING IS CONTROVERSIAL)
IF HYOID IS FRACTURED IT IS BEST TO REMOVE THE CENTRAL PORTION TO PREVENT CLICKING
FACIAL FRACTURES
PT NEEDS TO BE SEEN EMERGENTLY FOR:
REFERRING PHYSICIAN EXPRESSES CONCERN
OPHTHO CONCERNS—DYSTOPIA(ENOPTHALMOS, EXOPTHALMOS, ECT..), DIPLOPIA, VISUAL FIELD DEFICITS, HYPHEMA, GLOBE RUPTURE—LOOK FOR ABNL SHAPED IRIS, ECT…
COMMON SENSE/ NEED TO BE ADMITTED
LACERATIONS—CUTANEOUS OR MUCOSAL—-ALSWAYS BEST TO GET THE BEST RESULT POSSIBLE THE FIRST TIME!—- HUMAN(S.AUREUS AND EIKENELLA CORRODENS) OR ANIMAL(PASTUERELLA MULTICOCIDA) BITES CAN USUALLY BE CLOSED AFTER COPIOUS IRRIGATION IF WITHIN 12 HOURS—NEED TO TAKE OTHER INFXOUS PRECAUTIONS(RABIES, HIV, ECT….)—-PROBABLLY WOULD GIVE EVERYTHING A CHANCE AT PRIMARY CLOSURE—DON=T LOSE MUCH!
SEPTAL HEMATOMA
AURICULAR HEMATOMA
NASAL DEFORMITY—THAT CAN BE CORRECTED ACUTELY
OTHERWISE:
F/U IN CLINIC WITH CORONAL CT SCAN OF THE FACE
AFRIN PRN EPISTAXIS
KEFLEX FOR ANY SQ OR ORBITAL EMPHYSEMA
SNEEZE WITH MOUTH OPEN—-DO NOT BLOW NOSE
FRONTAL SINUS Fx
VERY CONTROVERSIAL–PUT ON ABX TO COVER STAPH AND STREP
MAY ONLY NEED TO MARSUPULIZE ANY SINUS MUCOCELES—-EVEN FRONTAL SINUS—-IN 32 CASES NO RECURRENCE—NO MALIGNANT DEGENERATION— SO ONLY FOLLOW SYMPTOMS—-NO NEED FOR REGULAR IMAGING—UTILIZE FLEXIBLE PEDS SCOPE TO ID FRONTAL SINUS DUCT—–DO FRONTAL SINUS FLOOR DRILL OUT
USE MRI TO HELP DIFFERENTIATE MUCOCELE FROM BACKED UP SECRETIONS AND OR ORBITAL CONTENTS
VERY CONTROVERSIAL AREA—IF YOU ARE IN THE SINUS AND THERE IS ANY QUESTION OF TRAUMA—AT LEAST RESECT THE INTERSINUS SEPTUM
POST WALL FX—CONSIDER CRANIALIZATION
OUTFLOW REGION FRACTURED—CONSIDER FAT OBLITERATION—DRILL OUT ALL MUCOSA AND PACK FRONTAO RECESS WITH MUSCLE
ANT CRANIAL FOSSA Fx
GET “SPECTACLE” HEMATOMA—ECCYMOSIS STOPPING AT THE ARCUS MARGINALIS—CSF RHINORHEA, ANOSMIA, AND ALTERED MENTATION—CAN PICK THESE UP WITH GOOD CT SCAN—USUALLY PNEUMOCEPHALUS—ABSOLUTELY NO TUBES IN THE NOSE
MANDIBLE FX
THE FORCE TO Fx A MANDIBLE CAN BREAK THE C-SPINE
ANY QUESTION OF BROKEN OR MISSING TEETH—-GET A CXR!
CLASS I OCCLUSION=NL= THE MESIAL-BUCCAL CUSP OF THE FIRST MAXILLARY MOLAR OPPOSES THE BUCCAL INTERCUSPAL GROOVE OF THE FIRST MANDIBULAR MOLAR.
CLASS II=MESIO-OCCLUSION-@BUCK TOOTH@–OVERBITE
CLASS III=DISTO-OCCLUSION-PROGNATHIA–@BULL DOG OR DICK TRACY LOOK@
AGES 7-11 ARE PRIMARY YEARS FOR MIXED DENTITION
UNIVERSAL SYSTEM FOR TOOTH NOMENCLATURE—–R-L TOP TO BOTTOM (START AND FINISH ON THE RIGHT)
ADULT—32 PERMANENT OR SECONDARY TEETH NUMBERED 1-32
CHILDREN—20 DECIDUOUS OR PRIMARY TEETH LETTERED A—T
TOOTH SURFACES—MESIAL (MIDLINE) VERSUS DISTAL —AND—- LINGUAL VS BUCCAL OR LABIAL
PRIMARY OR MIXED DENTITION IS DIFFUCULT TO WIRE—TEETH LACK A SINGULUM—CONSIDER CIRCUMANDIBULAR WIRES—-CONSIDER ORTHODONTIC SPLINTS
IMF IS THE GOLD STANDARD —FOR PEDS LEAVE IN 2-3 WEEKS—-MAY TAKE OUT WEEFKLY FOR PT TO AVOID ANKYLOSIS OF TMJ
ADULTS —GENERALLY LEAVE IN 4 WEEKS +
CLINICALLY A UNILATERAL SUBCONDYLAR FX WILL DEMONSTRATE IPSI DEVIATION OF THE CHIN ON OPENING THE MOUTH
BILAT FX MAY DEMONSTRATE APERTOGNATHIA
IF YOU HAVE GOOD TEETH ON EITHERSIDE OF THE Fx CAN GENERALLY USE IMF–WITH THE EXCEPTION OF SYMPHASEAL Fx=S AS THE ACTION OF THE MASSETER TENDS TO SPLAY THE SEGMENTS LATERALLY—-EASY TO PUT A PLATE MIDLINE VIA INTRA-ORAL ROUTE—MAY GO EXTERNAL IF NO MUCOSAL TEARS TO KEEP CASE CLEAN
MMF IS THE UNDERUTILIZED AGOLD STANDARD@— LEAST COMPLICATIONS
24 GUAGE WIRE SEEMS TO CINCH DOWN BETTER—ERLICH ARCH BARS
CIRCUMANDIBULAR WIRES ARE GOOD OPTION FOR MIXED DENTITION
ILIAC CREST IS EXCELLENT GRAFT MATERIAL FOR MANDIBLE—CAN USE INNER OR OUTER TABLE OR FULL THICKNESS–KEEP MAXIMAL CANCELLOUS BONE
NEW EVIDENCE SHOWS MULT SMALL PERFS (DRILL HOLES) IN BOTH THE DONOR AND RECEIPIENT CORTEX HELPS IN TAKE
FIBULAR FREE FLAP IS GOOD OPTION FOR 3-D DEFECTS
GUNNING SPLINTS (VS ORIF) ARE GOOD FOR EDENTULOUS PTS
IF FOR SOME REASON YOU LOOSE ANT SUPPORT—-FLAIL ANT SEGMENT–ADMIT FOR AAIRWAY OBSERVATION@ BARTON BANDAGE FOR SUPPORT—PROBABLY JUST BETTER TO FIX RIGHT AWAY
CHRONIC TMJ PROBLEMS ARE COMMON—-ANT DISPLACEMENT OF THE ARTICULAR DISK
CONSIDER BONDED MMF—-FAST AND RELIABLE—CAN BE DONE IN CLINIC
BONEY EAC FX = COMMON—–SHOULD EXAMINE WITH MICROSCOPE AND REDUCE WITH NASAL SPECULUM—-IN NO CSF LEAK—-PACK WITH GEL FOAM OVER SKIN LACS AND THEN WITH 1/4″ NU GUAZE—LEAVE IN FOR 1 WEEK—F/U WITH AUDIO
TRUE RAMUS AND SUBCONDYLAR Fx CAN OFTEN BE MANAGED EXPECTANTLY WITH MMF AS THE Fx SITE HANGS IN A SLING OF MASSETER AND PTERYGOIDS AND WILL UNDOUBTEDLY HEAL
APPROACH ANGLE Fx EXTERNALLY—-RAISE A MINIMAL SUBPLATYSMAL FLAP AND GO DIRECTLY TO THE UNDERSURFACE OF THE ANGLE—-RELEASE THE MASSETER AS FAR AS NECESSARY WITH THE BOVIE
LEFORT Fx MANAGED WITH MMF WITH SUSPENSION WIRES MAY FORSHORTEN THE FACE
BONE PLATE EXPOSURE—ABX, IRRIGATE AND REMOVE AFTER 4 WEEKS WHEN Fx HEALED
A BONE PLATE AT THE EXTERNAL OBLIQUE LINE CAN CAUSE THERMAL SENSITIVITY OF THE TEETH
STAYING BELOW THE OBLIQUE LINE WILL KEEP YOU SAFE FROM IMPALING THE NERVE
NONUNION USUALLY CAUSED FROM MOBILITY AT THE Fx LINE
FOR AN OBLIQUE FX A LAG SCREW WORKS WELL—-SIMPLY OVERDRILL THE PROXIMAL FRAGMENT
INFXN AT THE Fx SITE USUALLY CAUSED BY A TOOTH IN THE Fx LINE
PICKEL FORK = GUAZE PACKER (ZITSCHISM)
AFTER PUTTING ON YOUR ARCH BAR—-CLAMP IT DOWN TIGHTLY WITH A CRILE TO THE TEETH AND RETIGHTEN
FOR HIGH RAMUS AND SUBCONDYLAR FxS—CONSIDER LEIBINGER IMF SCREWS—-PLACE JUST MEDIAL AND AWAY FROM THE CANINE ROOTS—-TIGHTEN DOWN WITH 22 GUAGE WIRE—CRANK IT—-WILL NEED TO REMOVE IN SDS!
INJURIES TO STENSON’S DUCT—-OFTEN IN CONJUNCTION WITH BUCCAL BRANCH OF 7—-REPAIR WITH A PERMANENT SUTURE OVER A SILASTIC STENT
NASAL Fx
THE MOST COMMON FACIAL BONE FRACTURED
CNR—BEST IF DONE EARLY PRIOR TO SWELLING
USE A WALSHMAN OR ASCH SEPTAL FORCEPS
DECONGEST NOSE (AFRIN/NEOSYNEPHRIN)
CAN USE TOPICAL PONTOCAINE (ESTER) OR COCAINE (ESTER)
COCAINE—SINGLE FATALITY FROM >400 MG
FAIRLY SAFE IF YOU DECONGEST FIRST
4 ML OF 4% = 160 MG (MOST SAY USE LESS THAN 2-3 MG/KG (SOME SAY 1 MG/KG)
INJECT TRANSCUTANEOUSLY 1% LIDO WITH 1/100,000 EPI
ANT ETHMOID/ INFRA-TROCHLEAR BRANCHES AT NASAL ROOT
EXT BR OF NASO-CILIARY NERVE ON NASAL DORSUM
INF ORBITAL NERVE
ANT SUP DENTAL NERVE
LET SET UP
REDUCE—DO NOT PACK IF YOU DO NOT HAVE TO—BENZOIN/STERISTRIPS/AQUAPLAST
NEC Fx
DIFFERENTIATE TELECANTHUS FROM HYPERTELORISM—MEASURE
MUST SECURE THE MEDIAL CANTHI—MAY NEED TO DO A DCR
A LOW CRIBRIFORM (RARE) WILL PREVENT REPAIR OF TELECANTHUS
NEC HAVE A 3% INCIDENCE OF BLINDNESS
RESULT IN A PIG NOSE DEFORMITY
MAXILLARY/MIDFACE FRACTURE
REPAIR FOR 1) FORM AND 2) FUNCTION
3 PAIRS OF HORIZONTAL BEAMS:
FRONTAL BAR
INF ORBITAL RIMS—ZYGOMATIC ARCHES
ALVEOLAR PROCESS OF MAXILLA
3 PAIRS OF VERTICAL BUTRESSES:—VERATICAL BUTRESSES ARE STRONGER THAN THE HORIZONTAL BEAMS
NASOMAXILLARY BUTTRESS
ZYGOMATICOMAXILLARY BUTTRESS
PTERYGOMAXILLARY BUTTRESS
ALWAYS DEFINE AND DESCRIBE THESE IN YOUR EXAM!
ALWAYS CHECK THE PALATE FOR A SAGITAL SPLIT
FORM:
CHEEK PROJECTION (MALAR EMMINENCE)—ORBITAL RIM—DYSTOPIA(ENOPTHALMOS)—STRABISMUS/ENTRAPMENT,—IF GREATER THAN 50% OF THE ORBITAL FLOOR COMMINUTED OR ABSENT CAN ANTICIPATE EVENTUAL ENOPHTHALMOS
FUNCTION:
OCCLUSION,—LOSS OF VISUAL ACUITY OR DIPLOPIA FROM EITHER DYSTOPIA(ENOPTHALMOS), IMPINGEMENT(BONEY SPICULES), OR ENTRAPMENT—–ENOPTHALMOS MAY MANIFEST AS — PSEUDOPTOSIS OF THE UPPER EYELID, ACCENTUATION OF THE UPPER EYELID SULCUS, AND NARROWING OF THE PALPEBRAL FISSURE.
K-WIRE OR T-MALAR DISIMPACTION SCREW (CAROL-GIRARD SCREW) WORKS WELL FOR ZMC Fx=S—3-D CONTROL
MORE OFTEN ON LEFT (DUE TO RIGHT HANDED ASSAILANTS)
FOLEY OR PENROSE IN MAXILLARY SINUS MAY AID IN SPLINTING THE ORBITAL FLOOR
ZYGOMATIC ARCH Fx
SOMEWHAT RARE IN ISOLATION—-FIX AGAIN FOR FORM OR FUNCTION
BEST TO REPAIR EARLY (WITHIN 48 HOURS)
CAN IMPINGE ON THE TEMPORALIS AND CAUSE TRISMUS—-PERSISTENT POST REDUCTION TRISMUS CAN BE DUE TO A CORONOID PROCESS Fx
REALLY 3 APPROCHES—-GILLIES, KEEN, AND LAT BROW
GILLIES PROBABLY WORKS THE BEST AND AVOIDS A CONTAMINATED FIELD
EASIEST UNDER GENERAL—INJECT FOR HEMOSTASIS—-WILL PROBABLY GET A LOCAL INDUCED FRONTAL PARESIS
CUT IN THE DIRECTION OF THE FRONTAL BRANCH ABOUT 2-3 CM BEHIND THE HAIRLINE—TRY TO STAY ABOVE THE TEMPORATL FAT PAD—-THIS AREA IS CONFUSING—-CONSIDER THE AURICULARIS MUSCLES—THEY MOVE!
GET DOWN TO THE TRUE TEMPORALIS FASCIA—THICK AND IMMOBILE—INCISE IT AND VEIW THE TEMPORALIS MUSCLE—–DEVELOPE YOUR PLANE WITH A FREER—–MEASURE IT OUT—–DRAW THE FX AND THE FRONTAL BR OF 7 ON THE PTS SKIN FOR REFERENCE
YOU WILL NOT BE ABLE TO PALPATE YOUR ELEVATOR IF IT IS IN THE CORRECT PLANE—THE TRUE FASCIA RUNS DEEP!—-IT YOU ARE PALPATING THE ELEVATOR YOU ARE IN THE WRONG PLANE AND ARE IN DANGER OF DAMAGING THE FACIAL NERVE
CONFUSING ANATOMY— -THE SUPERFISCIAL TEMPORAL FASCIA IS THE TEMPOROPARIETAL FASCIA AND ORIGINATES ON THE ZYGOMATIC ARCH—IS CONTIGUOUS WITH THE GALEA/FRONTO-OCCIPITALIS
FRONTAL BR LIES ON ITS UNDERSURFACE
THE SUPERFICIAL LAYER OF THE DEEP TEMPORAL FASCIA (INNOMINATE FASCIA) OVER LIES THE TEMPORALIS MUSCLE—-DIVIDES FROM THE DEEP LAYER TO ENCOMPASS THE SUPERFICILA TEMPORAL FAT PAD LAT TO THE ORBIT—THIS PORTION ATTACHES INF TO THE SUP ZYGOMATIC RCH PERIOSTEUM
THE DEEP LAYER OF THE DEEP TEMPORAL FASCIA FOLLOWS THE MUSCLE UNDER THE ARCH TO THE CORONOID—THUS UNDERLIES THE TEMPORAL FAT PAD—THEN ALSO BLENDS IN TO THE ZYGOMATIC ARCH PERIOSTEUM—-YOU WANT TO STAY DEEP TO THIS FASCIA!!!
REDUCE THE THE Fx WITH A GILLIES ELEVATOR—-DO NOT FULCRUM ON THE SKULL—IT WILL FX IN THIS REGION–JUST LIFT THE PTS HEAD UP WITH THE ELEVATOR
IF THE FRAGMENT IS STILL MOBILE—-MAY PACK IT (CONSIDER SURGICEL/PENROSE/FOLEY/EPISTAT)—-PROBABLY GIVE ABX AND SEND THEM HOME WITH ABX AND PAIN MEDS
GIVE NSAIDS AND INSTITUTE RIGOROUS PHYSICAL THERAPY TO COMBAT TRISMUS
ORBITAL (BLOWOUT) FLOOR FRACTURE
PRESENT WITH EXOPTHALMIA DUE TO SWELLING—– DYSTOPIA(ENOPTHALMOS)—STRABISMUS/ENTRAPMENT,—IF GREATER THAN 50% OF THE ORBITAL FLOOR COMMINUTED OR ABSENT CAN ANTICIPATE EVENTUAL ENOPHTHALMOS
OCCLUSION,—LOSS OF VISUAL ACUITY OR DIPLOPIA FROM EITHER DYSTOPIA(ENOPTHALMOS), IMPINGEMENT(BONEY SPICULES), OR ENTRAPMENT—–ENOPTHALMOS MAY MANIFEST AS — PSEUDOPTOSIS OF THE UPPER EYELID, ACCENTUATION OF THE UPPER EYELID SULCUS, AND NARROWING OF THE PALPEBRAL FISSURE.
CHECK PUPILS—LOOK FOR EPIPHORA
IF RETINA DAMAGED OR DEAD—MUST REMOVE (ENUCLEATION) TO AVOID A SYMPTHETIC AUTOIMMUNE CONTRALATERAL RETINOPATHY
PINNA (AURICULAR) TRAUMA—-CLOSE LACS– FOR AVULSIONS MAY USE POCKET OR TUNNEL TECHNIQUE—RAISE THE EAR LATER WHEN THE WOUND IS HEALED
AURICULAR HEMATOMA
USUALLY ANTERIOR—SKIN TIGHTLY ADHERED TO UNDERLYING PERICHONDRIUM—SHEARING TRAUMA SEPARATES THE PERICHONDRIUM FROM THE CARTILAGE (POSTERIOR SHEARING RESULTS IN SUBCUTANEOUS HEMATOMAS WHICH USUALLY RESOLVE SPONTANEOUSLY AND COMPLETELY)
ANT=SUBPERICHONDRIAL HEMATOMAS RESULT IN THE FORMATION OF FIBRONEOCARTILAGE AFTER ABOUT DAY 7-10—–THIS LATER FORMS STABLE FIBROSIS AND RESULTANT ACLASSIC CAULIFLOWER EAR@
IF YOU SEE THE PT PRIOR TO 5 DAYS YOU CAN USUALLY I&D WITH 2 ANT INCISIONS HIDDEN IN THE HELICAL CREASE AND BOLSTER IT WITH COTTON BALLS AND THROUGH AND THROUGH 3-0 NYLON SUTURES—-PLACE A WICK IN THE EAC AND START DROPS—CAN USUALLY DO THIS WITH 10 CC LIDO WITH EPI IN A RING BLOCK—PLACE A RATHER TIGHT MASTOID DSG AND LEAVE IT ON FOR 24 HOURS AND THEN MAY REMOVE IT PERIODICALLY TO PLACE THE DROPS—-START CIPRO 500MG PO BID
SEE THEM BACK IN 5-7 DAYS FOR REMOVAL OF THE DSG AND DEBRIDEMENT
IF YOU GET LESS THAN AN OPTIMAL RESULT OR IF THEY ARE TOO FAR OUT SHEDULE A REVISION IN THE CLINIC—DO A RING BLOCK CONCENTRATING ON THE GREATER AURICULAR—-MAY GET SOME RESIDUAL SENSATION IN THE CONCHAL AND MEATAL REGION FROM CN 7 (HITTSELBERGER=S) NERVE—-RAISE A SUBPERICHONDRIAL FLAP—DISSECT OUT THE FIBRONEOCARTILAGE OR CONTOUR THE FIBROSIS—-PLACE A SMALL PASSIVE PENROSE AND CARFULLY BOLSTER IT DOWN WITH 4-O PROLENES—-MAY USE A POST AURICULAR INCISION OR HIDDEN ANT INCISIONS
PLACE ON CIPRO
S/U IN CLINIC IN 2 DAYS FOR DRAIN REMOVAL AND RECHECK
REMOVE BOLUS DSG IN ABOUT 10 DAYS
T-BONE TRAUMA
30% OF ALL CHI HAVE A SKULL FX
18% OF ALL SKULL FX INVOLVE THE TEMPORAL BONE
33-50%OF ALL CHI HAVE A SNHL=THE MOST COMMON SEQUELAE OF CHI
CN 6 IS THE MOST FREQUENTLY INJURED CN (LR PAULSEY)
FULL RECOVERY IF ONLY LOW FREQ
PARTIAL RECOVERY IF ONLY HIGH FREQ
15% CHI WILL SUFFER A CHL
HEMOTYMPANUM TAKES ABOUT 6-8 WKS TO RESOLVE(CHL RESOLVES IN 4WKS)
I-S JOINT SEPARATION
STAPES CRURA FX
MALLEUS IS RARELY INJURED
0.7% CHI RESULT IN FACIAL PARALYSIS
T-BONE Fx/BASILAR SKULL Fx
REALLY MOST MIXED
1-6% WILL HAVE A CSF LEAK
OLD FIGURES FROM IMPACT STUDIES DONE ON THE 40’S
80-90% LONG, 10-20% TRANSVERSE, 8% BILAT
STENVER PROJECTION USEFUL RADIOGRAPHICALLY IN ANTIQUITY
MUST GET FINE CUT CT OF T-BONES
Hx
HL,TINNITUS,AUTOPHONY,VERTIGO,FACIAL WEAKNESS,FACIAL HYPETHESIAS,DIPLOPIA,OTORRHEA,RHINORHEA
HISTORICALLY INITIAL FUNCTION (DELAYED VS IMMEDIATE) THOUGHT TO BE IMPORTANT—-HOWEVER NOW THEY SEEM TO DO EQUALLY WELL—-AS WITH MOST THINGS DELAYED MAY WELL MEAN DELAYED RECOGNITION
PE
HEMOTYMP,RACOON EYES,BATTLES SIGN,BLOOD IN EAC,TUNING FORKS,NYSTAGMUS,TOPODIAGNOSTIC TESTS,TM STATUS,CN FUNCTION,FISTULA TEST, (B FACIAL PARALYSIS MAY BE HARD TO DETECT)
ANCILLARY
CT,AUDIO,ENOG
HEMOTYMPANUM USUALLY RESOLVES IN 1-3 MONTHS—-USED DTO USE BLOOD IN THE ME AS PACKING FOR A T-PLASTY
LONGITUDINAL
TRIAD:LOC, CHL, BLOODY OTORHEA
80%-90% OF T-BONE Fx=S
20%-25% OF THESE SUFFER FACIAL PARALYSIS(THE OVERALL MAJORITY OF FN PARALYSIS)
FROM TEMPERO-PARIETAL TRAUMA(LAT. SKULL)(MINOR TRAUMA)
Fx TENDS TO RUN PARALLEL TO THE EAC–THROUGH THE MIDDLE EAR
MIDDLE EAR ALMOST ALWAYS INVOLVED
HEMOTYMPANUM IF TM INTACT
RARELY CSF LEAK
OSSICULAR DAMAGE COMMON(I-S JOINT SEPARATION > STAPES INJURY))—-FOR STAPES SUBLUXATION LOOK FOR PNEUMOLABYRINTH
ROOF OF THE EAC OFTEN FRACTURED—IMPORTANT TO LOOK FOR TYMPANIC RING Fx AND AVOID GETTING SQUAM IN THE MIDDLE EAR
BATTLE=S SIGN(POST AURICULAR A.—–MASTOID ECCYMOSIS)
MAY INVOLVE FORAMEN LACERUM (DORELLOS CANAL) OR FORAMEN OVALE (V3)
MAY INVOVE EUSTACION TUBE
B 10-20%!—B FACIAL PARALYSIS MAY LOOK LIKE LACK OF AFFECT
USUALLY ANT. TO THE OTIC CAPSULE
CAN HAVE PLF FROM STAPES SUBLUXATION INTO THE O.W.
TRANSVERSE
TRIAD:SNHL(ANACUSIS), SPONT. NYSTAGMUS(DEBILITATING VERTIGO), FACIAL PARALYSIS
10-20% OF T-BONE Fx=S
FROM FRONTAL OR OCCIPITAL TRAUMA(MASSIVE)
Fx RUNS FROM THE FORAMEN MAGNUM TANSVERSELY ACROSS THE PETROUS APEX ACROSS THE IAC AND OTIC CAPSULE, ENDING AT THE FORMAMEN SPINOSUM(MMA) OR LACERUM(CN6)
OTIC CAPSULE AND IAC RUPTURE COMMON
SNHL AND VERTIGO COMMON
HEMOTYMPANUM
CSF LEAK COMMON(SALTY TASTE WORSE WITH HEAD DOWN)
FACIAL NERVE PARALYSIS 50%( DISTAL LABYRINTHIAN SEGMENT)
EAC INTACT
TM USUALLY INTACT
MAY INVOLVE THE JUGULULAR FORAMEN OR FOMAMEN MAGNUM
NO T-BONE Fx ROUTINELY INVOLVES THE SMF
IF YOU ARE GOING TO DECOMPRESS—ASSESS THE HEARING—MAY NEED ABR—-ANY USEFUL HEARING GO MIDDLE FOSSA—NO GOOD HEARING GO TRANSLAB
CSF LEAK
PRIMARILY POST TRAUMATIC —RARELY SPONTANEOUS
MANIFEST USUALLY AS OTORRHEA OR RHINORRHEA—A MIDDLE EAR LEAK WILL MANIFEST AS RHINORRHEA IF THE TM IS INTACT
MOST COMMON LEAK SITE=CRIBRIFORM PLATE
Dx: CLEAR WATERY PULSATILE EXTRAVASATION OF FLUID
PT REPORTS A SALTY TASTE
RING, DOUBLE RING, HALO, OR TARGET SIGN ON BEDDING—-FLUID SEPARATES INTO BLOOD RING AND EXTERNAL CSF RING
GLC > 30-35% NL WITHOUT MENINGITIS—–EXAMINE QUICKLY TO AVOID FERMENTATION
BETA-2-TRANSFERRIN PROTEIN ELECTROPHORESIS—ABSENT IN TEARS, SERUM, AND NASAL SECRETIONS EXCEPT IN NEONATES AND PTS WITH LIVER Dz
CT CISTERNOGRAPHY WITH WATER SOLUBLE CONTRAST MATERIAL (MATRIZAMIDE SCAN)—LEAK NEEDS TO BE FAIRLY BRISK TO PICK THIS UP
Rx: PRIMARILY CONSERVATIVE WITHOUT ABX—NON-OCCLUSIVE MASTOID DSG AND OBSERVATION–(CONTROVERSIAL)—–CHECK VS Q 2 HOURS—-IF DEV SIGNS AND Sx OF MENINGISMUS—TREAT WITH VANC FORTAZ AND FLAGYL EMPIRICALLY JUST AFTER GETTING AN LP
BEDREST, HOB > 30 DEGREES, AVOID VALSALVA, POS PRESSURE VENTILATION (AVOID USING FACE MASK), AVOID BLOWING NOSE, SNEEZE WITH MOUTH OPEN, STOOL SOFTENERS
IF GOING TO OR—GIVE IV ABX 10 HOURS OCOR
ACETAZOLAMIDE 250 MG PO QID DECREASES CSF PRODUCTION
MODEST FLUID RESTRICTION (75% OF MAINTAINENCE)
CONSIDER LUMBAR DRAIN
GET I.D. CONSULT—–EMPIRICALLY CULTURE NOSE AND THROAT——-80+% PNEUMOCOCCUS
CONSIDER REPAIR WITH AUTOLOGOUS FATFIBRIN GLUEMUCOPERIOSTEAL FLAP ECT…….
MAJORITY RESOLVE WITHIN 10-14 DAYS