Head and Neck Trauma E-Book

Michael Herzog

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 401

Veröffentlichungsjahr: 2006

Beschreibung

Written by an interdisciplinary team of experts in ear, nose, and throat trauma; oral and maxillofacial surgery; neurosurgery; and accident surgery, this book is a state-of-the-art manual on the diagnostic, treatment, and therapeutic techniques available to manage trauma injuries to the head and neck. This book features more than 240 illustrations, most in color, and step-by-step discussions of the initial management, evaluation, and examination of the patient, followed by a thorough collection of flow-charts and checklists. In each chapter the authors present the surgical anatomy, pathomechanism and classification, clinical signs and symptoms, functional tests, diagnostic imaging, as well as other appropriate diagnostic measures. Head and Neck Trauma covers everything from wound management to the latest surgical techniques and their complications. The authors also discuss the medical and technical aspects of trauma management, including antibiotic therapy, grafting and osteosynthesis materials, and the assessment of posttraumatic functional disorders. This beautifully illustrated reference belongs in every emergency room and trauma center library and is an essential tool for any medical professional treating patients with head and neck injuries.

Leseprobe

Library of Congress Cataloging-in-Publication Data

Ernst, Arne, 1958-[Traumatologie des Kopf-Hals-Bereichs. English]Head and neck trauma/Arne Ernst, Michael Herzog,Rainer Ottis Seidl; with contributions by Karl-Ludwig Kiening,Andreas Unterberg, Ulrich W. Thomale.

p.; cm.

Includes index.ISBN-13: 978-3-13-140001-7 (GTV: alk. paper)ISBN-10: 3-13-140001-3 (GTV: alk. paper)ISBN-13: 978-1-58890-437-9 (TNY: alk. paper)ISBN-10: 1-58890-437-7 (TNY: alk. paper) 1. Neck—Wounds andinjuries. 2. Head—Wounds and injuries. I. Herzog, Michael, MD.II. Seidl, Rainer Ottis. III. Title.[DNLM: 1. Craniocerebral Trauma. 2. Neck Injuries.3. Reconstructive Surgical Procedures. WL 354 E71 t 2006]RD521.E76 2006617.5′1044–dc22

2006012337

This book is an authorized and revised translationof the German edition published and copyrighted 2004by Georg Thieme Verlag, Stuttgart, Germany.Title of the German edition: Traumatologie des Kopf-Hals-Bereiches

Translator: Stephanie Kramer, BA, Dipl Trans, IoL, Berlin

Illustrators: Peter Haller and Joachim Hormann, Stuttgart

2006 Georg Thieme Verlag,Rüdigerstrasse 14, 70469 Stuttgart, Germanyhttp://www.thieme.deThieme New York, 333 Seventh Avenue,New York, NY 10001, USAhttp://www.thieme.com

Typesetting by Sommer Druck, FeuchtwangenPrinted in Germany by Appl, Wemding10-ISBN 3-13-140001-3 (GTV)13-ISBN 978-3-13-140001-7 (GTV)10-ISBN 1-58890-437-7 (TNY)13-ISBN 978-1-58890-437-9 (TNY)       1 2 3 4 5 6

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Preface

The treatment of patients with head and neck trauma requires a highly professional, fast, and multidisciplinary approach. There might be certain regional differences around the globe, but in most countries anesthesiologists, trauma surgeons, neurosurgeons, ear, nose, and throat (ENT) specialists, and oral and maxillofacial surgeons (OMS) are primarily involved.

While initial management is usually limited to identifying and treating life-threatening conditions, later steps in the adequate management of the consequences of head and neck trauma generally belong to only a few specialized fields. The present book is the product of a long-standing, clinical cooperation between the Departments of Otorhinolaryngology and Maxillo-Facial Surgery at the Berlin Trauma Center (UKB), with an additional neurosurgical contribution.

The book is intended to serve as a guide, providing all those involved in the care of patients with head and neck trauma basic as well as specialized knowledge. Flow charts, special sections detailing “Rules and Pitfalls,” and case reports serve as a quick bedside manual, with the entire work representing an extensive textbook.

The book reflects this approach and is divided into sections on initial management, diagnosis, and therapy. In addition, numerous cross-references facilitate the linking of symptoms, evaluation, and management.

We would like to take this opportunity to thank the staff members at our departments who are also responsible for conducting the annual training course on “Head and Neck Trauma Management” in Berlin. Additionally, we would like to express our gratitude to Professor Sven Mutze, Director of the Institute for Radiology at UKB, for permission to use the images printed in this book and also to Thieme Publishing Group, in particular, Dr. Urbanowicz for his patient support in the completion of this book.

We sincerely hope that the English edition of our book will find many readers across the globe, even though a few differences may exist for the management of head and neck trauma.

Arne ErnstMichael HerzogRainer O Seidl

Contributors

Karl-Ludwig Kiening, MDAssociate ProfessorNeurosurgical University HospitalHeidelberg UniversityHeidelberg, Germany

Ulrich W Thomale, MDNeurosurgical DepartmentCharité University HospitalBerlin, Germany

Andreas Unterberg, MDProfessorNeurosurgical University HospitalHeidelberg UniversityHeidelberg, Germany

Contents

I   Evaluation of Head and Neck Trauma

1 Initial Management

First Aid at the Scene

Evaluation of Vital Functions

Stabilizing Vital Functions

Stabilizing Circulation

Emergency Care

Emergency Measures

Airways

Fall-Back of the Tongue

Injuries of the Larynx and Trachea

Hemorrhage

Central Hemorrhage

Peripheral Hemorrhage

Priorities in Trauma Management

2 Examining the Patient

Patient History

Inspection

Palpation

Functional Testing

Radiologic Diagnostics

3 Flow Charts and Checklists

Initial Management

Initial Evaluation

Injuries of the Neurocranium

Injuries of the Skull Base

Injures of the Ear and Lateral Skull Base

Injuries of the Facial Nerve

Craniofacial Injuries

Injuries of the Orbits

Dental Injury

Injuries of the Neck

4 General Principles of Trauma

Cutaneous Wounds

Pathomechanism and Classification

Wounds Caused by Mechanical Forces

Thermal and Chemical Wounds

Skin Healing

Osseous Injuries

Pathomechanism and Classification

Fracture Signs

Bone Healing

Direct (Primary) Fracture Healing

Indirect (Secondary) Fracture Healing

Pseudarthrosis

Fracture Treatment

Reduction

Fixation

Retention

Immobilization

Rehabilitation and Functional Therapy

Injuries of the Joints

Pathomechanism and Classification

Cartilage Injury

Pathomechanism and Classification

Cartilage Healing

Muscular Injury

Clinical Signs and Symptoms

Muscular Healing

Peripheral Nerve Injury

Pathomechanism and Classification

Neural Healing

II  Diagnostic of Head and Neck Trauma

5 Injuries of the Neurocranium and Craniocervical Junction

Injuries of the Neurocranium

Open and Closed Head Injury

Clinical Signs and Symptoms

Diagnostic Imaging

Treatment

Injury to Bony Structures of the Craniocervical Junction

Anatomy and Pathomechanism

Clinical Signs and Symptoms

Classification

Diagnostic Imaging

Soft Tissue Distortion and Discoligamentous Injuries of the Craniocervical Junction

Pathomechanism

Clinical Signs and Symptoms

Classification

Clinical and Neurological Diagnosis

Imaging Modalities

6 Diagnosing Injuries of the Skull Base

Surgical Anatomy

Anterior Cranial Fossa

Middle Cranial Fossa

Posterior Cranial Fossa

Pathomechanism and Classification

Pathomechanism

Dural Injury

Classification of Fractures

Clinical Signs and Symptoms

Uncertain Signs of Fracture of the Anterior Skull Base

Eyelid Hematoma, Eyelid Emphysema

Epistaxis

Seiferth Sign

Olfactory Disturbances

Certain Signs of Fracture of the Anterior Skull Base

Cerebrospinal Fluid Rhinorrhea

Evaluation of Suspected Cerebrospinal Fluid Rhinorrhea

Pneumocephalus

Early Meningitis

Diagnostic Imaging of Fractures of the Anterior Skull Base

Surgical Indications in Injuries of the Anterior Skull Base

7 Diagnosing Injuries of the Ear and Lateral Skull Base

Surgical Anatomy

Pathomechanism and Classification

Injuries of the External Ear

Injuries of the Middle Ear

Injuries of the Tympanic Membrane

Ossicular Injuries

Rupture of the Round Window Membrane

Injuries of the Petrous Temporal Bone and Labyrinth

Concussion of the Petrous Temporal Bone and Bony Labyrinth

Fractures of the Petrous Temporal Bone and Bony Labyrinth

Fracture Line in Longitudinal Fractures

Fracture Line in Transverse Fractures

Clinical Signs and Symptoms

Aural Hemorrhage

Cerebrospinal Fluid Otorrhea

Hearing Dysfunction

Sensorineural Hearing Loss

Conductive Hearing Loss

Vestibular Disorder

Functional Testing of the Auditory and Vestibular System

Audiometry

Tuning Fork Tests

Pure Tone Audiometry

Vestibular Tests

Frenzel Lenses

Vestibulospinal Reflexes

Romberg Test

Unterberger Stepping Test

Caloric Testing

Diagnostic Imaging

8 Diagnosing Injuries of the Facial Nerve

Surgical Anatomy

Intracranial Segment

Intratemporal Segment

Pathomechanism and Classification

Classification

House–Brackmann Scale

Clinical Signs and Functional Tests

Topodiagnostic Evaluation

Tearing (Schirmer Test)

Taste

Measurement of Stapedial Reflex

Electrophysiologic Testing

Electromyography (EMG)

Management

9 Diagnosing Injuries of the Midface

Surgical Anatomy

Classification of Midface Fractures

Central Fractures of the Midface

Fractures of the Alveolar Process

Pathomechanism

Le Fort I Fractures

Pathomechanism

Clinical Symptoms

Diagnostic Imaging

Treatment

Le Fort II Fractures, Wassmund I Fractures

Pathomechanism

Clinical Symptoms

Diagnostic Imaging

Treatment

Le Fort III Fractures, Wassmund IV Fractures

Surgical Anatomy

Pathomechanism

Clinical Symptoms

Diagnostic Imaging

Treatment

Fractures of the Nasoethmoidal Complex

Surgical Anatomy

Pathomechanism

Classification

Clinical Symptoms

Diagnostic Imaging

Treatment

Fractures of the Bony Nasal Framework and Septum

Surgical Anatomy

Pathomechanism

Classification

Clinical Symptoms

Diagnostic Imaging

Treatment

Fractures of the Lateral Midface

Zygomatic Fracture

Surgical Anatomy

Pathomechanism

Classification

Clinical Signs

Zygomatic Arch Fracture

Pathomechanism

Clinical Signs

Diagnostic Imaging

Treatment

10 Diagnosing Injuries of the Orbit

Surgical Anatomy

Orbital Wall Fractures

Fractures of the Orbital Floor and Medial Orbital Wall

Pathomechanism

Clinical Signs and Symptoms

Traction Test/Forward Traction Test

Endoscopy of the Maxillary Sinus

Diagnostic Imaging

Treatment

Fractures of the Orbital Roof and Lateral Orbital Wall

Pathomechanism

Clinical Signs and Symptoms

Diagnostic Imaging

Treatment

Injuries of the Orbital Apex

Pathomechanism and Classification

Clinical Signs and Symptoms

Injury of the Oculomotor Nerve

Injury of the Trochlear Nerve

Injury of the Abducens Nerve

Injury of the Optic Nerve

Injury of the Trigeminal Nerve

Diagnostic Imaging

Treatment

Injuries of the Lacrimal Ducts

Pathomechanism

Clinical Signs and Symptoms

Diagnostic Imaging

Treatment

Carotid-Cavernous Sinus Fistula

Pathomechanism

Clinical Signs and Symptoms

Diagnostic Imaging

11 Diagnosing Injuries of the Mandible

Surgical Anatomy

Pathomechanism

Clinical Signs and Symptoms

Certain Signs of Fracture

Deformity and Dislocation

Abnormal Mobility

Crepitus

Uncertain Fracture Signs

Hematoma and Swelling

Tenderness

Longitudinal Compression Pain

Restricted Function

Sensory Disturbances

Malocclusion

Diagnostic Imaging

Classification of Mandibular Fractures

Fractures of the Mandibular Body with Dentoalveolar Involvement

Pathomechanisms

Diagnostic Imaging

Treatment

Mandibular Fractures without Dentoalveolar Involvement

Clinical Signs and Symptoms

Diagnostic Imaging

Treatment

Fractures of the Ramus of Mandible

Pathomechanism

Clinical Signs

Diagnostic Imaging

Treatment

Injuries of the Condylar Process

Contusion of the Temporomandibular Joint

Distortion of the Temporomandibular Joint

Dislocation of the Temporomandibular Joint

Subluxation of the Temporomandibular Joint

Fracture of the Temporomandibular Joint

12 Diagnosing Dental Injuries

Surgical Anatomy

Pathomechanism

Dental Fractures

Classification

Clinical Diagnosis

Diagnostic Imaging

Treatment

Dental Luxation

Pathomechanism

Classification

Clinical Diagnosis

Diagnostic Imaging

Treatment

Dental Concussion

Pathomechanism

Diagnostic Imaging

Treatment

Dental Luxation without Dislocation (Loosening, Subluxation)

Pathomechanism

Clinical Signs

Diagnostic Imaging

Treatment

Dental Luxation with Dislocation

Partial Peripheral Dislocation

Complete Peripheral Dislocation

Central Luxation

Fractures of the Alveolar Process

Pathomechanism

Clinical Signs

Diagnostic Imaging

Treatment

13 Diagnosing Injuries of the Pharynx, Salivary Glands, and Soft Tissues of the Neck

Injuries of the Pharynx

Injuries of the Salivary Glands

Soft Tissue Injuries of the Neck

Blunt Trauma to the Soft Tissues of the Neck

Sharp Trauma of the Soft Tissues of the Neck

14 Diagnosing Injuries of the Larynx and Trachea

Surgical Anatomy

Pathomechanism and Classification

Fractures

Anteroposteriorly Directed Trauma

Lateral Trauma

Supraglottic Injuries

Transglottic Injuries

Subglottic Injuries

Tracheal Injuries

Ruptures

Supraglottic Rupture

Subglottic Rupture

Laryngotracheal Separation

Partial Laryngotracheal Separation

Complete Laryngotracheal Separation

Esophageal Rupture

Clinical Signs and Symptoms

Respiratory Distress

Emphysema

Complications

Evaluation Procedures and Functional Testing

Endoscopy

Magnifying Laryngoscopy and Flexible Nasopharyngolaryngoscopy

Microlaryngoscopy, Tracheobronchoscopy

Radiographic Evaluation

Evaluation of Phonation

Stroboscopy

Vocal Output and Characteristics

Electrodiagnostic Testing

Treatment

III Therapy of Head and Neck Trauma

15 Principles of Wound Management

The Ten Commandments of Wound Management

Abrasions

Immediate Management/Treatment

Puncture Wounds

Immediate Management

Treatment

Cut Wounds

Immediate Management

Treatment

Bite Wounds

Immediate Management

Treatment

Missile Wounds

Immediate Management

Treatment

Burn Injury

Immediate Management

Treatment

Chemical/Alkali Burns

Immediate Management

Treatment

Wound Closure

Suture Technique

Suture Material

Wound Dressings

16 Treatment of Injuries of the Neurocranium and Craniocervical Junction

Treatment Principles for Craniocerebral Trauma

Treatment of Fractures of the Craniocervical Junction

Atlantooccipital Fractures/Dislocations

Treatment of Soft Tissue Distortion and Discoligamentous Injuries of the Craniocervical Junction

17 Treatment of Injuries of the Skull Base

Indications

Approaches

Ear-to-Ear Scalp Incision, Bicoronal Incision

Frontoorbital Approach

Endonasal Approach

Surgical Technique

Principles of Dural Repair

Frontal Sinus

Extradural Management

Intradural Management

Ethmoid Bone

Sphenoid Sinus

Grafts

Autogenous Grafts

Homologous Grafts

Alloplastic Implants

Postoperative Management

Frontal Sinus

Ethmoid/Sphenoid Sinus

Drainage of Cerebrospinal Fluid

Follow-up Care

Complications

18 Treatment of Injuries of the Ear and Lateral Skull Base

Injuries of the External Ear

Indications

Surgical Methods

Seroma and Hematomas of the Ear

Injuries of the Auricle

Auricular Amputation

Injuries of the Vestibulocochlear System

Indications

Conservative Management

Inner Ear Auditory Dysfunction

Vestibular Disorder

Surgical Management

Approaches

Surgical Techniques

Injuries of the Facial Nerve

Indications

Conservative Treatment

Surgical Management

Follow-up Care

19 Treatment of Injuries of the Midface

Conservative Management

Splinting

Intraoral Splinting

Extraoral Splinting

Controlled Spontaneous Healing

Monomaxillary Fixation

Intermaxillary Fixation

Intermaxillary Fixation and Stabilization with a Halo Frame

Surgical Procedures

Craniofacial Suspension Wiring

Osteosynthesis with Miniplates and Microplates

Osteosynthesis Techniques

Osteosynthesis Materials

Osteosynthesis Systems

Principles of Reconstruction

Infrazygomatic Fractures (Le Fort I)

Indications

Conservative Management

Surgical Treatment

Complications

Central or Pyramidal Fractures (Le Fort II, Wassmund I)

Indications

Conservative Management

Surgical Technique

Complications

Centrolateral Fractures (Le Fort III, Wassmund IV)

Indications

Conservative Management

Surgical Technique

Complications

Fractures of the Nasoethmoidal Complex

Indications

Surgical Treatment

Fractures of the Bony Nasal Skeleton and Septum

Indications

Approaches

Surgical Technique

Fractures of the Lateral Midface

Indications

Approaches

Surgical Technique

20 Treatment of Orbital Injuries

Fractures of the Orbital Floor

Indications

Approaches

Surgical Technique

Complications

Medial Orbits

Indications

Approaches

Surgical Technique

Complications

Orbital Roof

Indications

Approaches

Surgical Technique

Complications

Orbital Decompression

Indications

Approaches

Surgical Technique

Complications

Optic Nerve Decompression

Indications

Approaches

Surgical Technique

Complications

Injuries of the Lacrimal Ducts

Indications

Surgical Technique

Complications

Injuries of the Eyelids

Indications

Surgical Technique

Complications

21 Treatment of Injuries of the Mandible

Fractures of the Mandibular Body with Dentoalveolar Involvement

Indications

Conservative Management

Surgical Management

Approaches

Surgical Technique

Complications

Fractures of the Mandible without Dentoalveolar Involvement or in the Partially Edentulous Jaw

Fractures of the Mandibular Ramus

Conservative Treatment

Surgical Treatment

Approaches

Surgical Technique

Complications

Fractures in the Edentulous, Atrophied Mandible

Mandibular Defect Fractures

Contaminated Mandibular Fractures

Fractures of the Mandible in Patients with Primary or Deciduous Teeth

Nondisplaced Fractures of the Condylar Neck and Head

Indications

Conservative Treatment

Surgical Treatment

Approaches—Intraoral Approach

Approaches—Extraoral Retromandibular (Submandibular) Approach

Functional Treatment

Displaced Fractures and Fracture-Dislocations of the Condylar Neck

Indications

Conservative Management

Complications

Surgical Management

Approaches

Surgical Technique

Complications

Fractures of the Condylar Head

Conservative Management

Surgical Treatment

Approaches

Surgical Technique

Fractures of the Articular Fossa (Central Dislocation)

Pediatric Fractures of the Condylar Neck and Condylar Head

22 Treatment of Dental Injuries

Treatment of Dental Injuries

Indications

Conservative Treatment of Crown Fractures

Enamel Fractures

Enamel-Dentin Fractures without Pulp Exposure

Enamel-Dentin Fractures with Pulp Exposure

Surgical Management of Root Fractures

Coronal Third Root Fractures

Middle Third Root Fractures

Apical Third Root Fractures

Longitudinal Fractures

Approaches (Resection of the Root Tip)

Surgical Technique

Complications

Treatment of Dental Luxation

Indications

Primary Teeth

Surgical Treatment

Dental Concussion

Dental Luxation without Displacement (Tooth Loosening)

Partial Peripheral Luxation

Complete Peripheral Luxation

Central Luxation

Complications

Treatment of Fractures of the Alveolar Process

Indications

Conservative Treatment

Surgical Management

Approaches

Surgical Technique

Complications

23 Treatment of Injuries of the Larynx, Pharynx, Trachea, Esophagus, and Soft Tissues of the Neck

Indications

Conservative Treatment

Chemical/Alkali Injuries

Surgical Therapy

Approaches

Surgical Procedure

Complications

IV Appendix

24 Antibiotic Therapy

25 Grafting and Osteosynthesis Materials

Requirements and Classification

Autogenic Grafts

Outer Table of the Skull

Allogenous (Homologous) Grafts

Preserved Allografts

Alloplastic Implants

Absorbable Alloplastic Implants

Polydioxanone (PDS)

Ethisorb

Vicryl

Monocryl

Nonabsorbable Alloplastic Implants

Metal

Further Reading

Index

I Evaluation of Head and Neck Trauma

1 Initial Management

First Aid at the Scene

Emergency Measures

Priorities in Trauma Management

2 Examining the Patient

Patient History

Inspection

Palpation

Functional Testing

Radiologic Diagnostics

3 Flow Charts and Checklists

Initial Management

Initial Evaluation

Injuries of the Neurocranium

Injuries of the Skull Base

Injures of the Ear and Lateral Skull Base

Craniofacial Injuries

Injuries of the Orbits

Dental Injury

Injuries of the Neck

4 General Principles of Trauma

Cutaneous Wounds

Osseous Injuries

Injuries of the Joints

Cartilage Injury

Muscular Injury

Peripheral Nerve Injury

1 Initial Management

Checklist Initial Evaluation, Chapter 3, p. 15

Checklist Initial Management, Chapter 3, p. 15

First Aid at the Scene

In areas where rapid access to medical care is ensured, persons arriving at the scene normally need only to call the paramedics and wait for their arrival. Securing the scene of the accident has absolute priority over further measures in order to protect the injured individual, motorists, and other persons administering aid.

Evaluation of Vital Functions

Vital signs should always be determined first as a means of initial assessment:

Neurologic status is evaluated on the basis of the patient's response when spoken to and to pain.

The Glasgow Coma Scale (GCS; Table 5.1, p. 39) is necessary for further clinical assessment.

Respiratory status is evaluated based on observation of breathing pattern and respiratory rate.

Circulation can be evaluated by palpating the carotid pulse.

Stabilizing Vital Functions

Obstruction of the upper airways is the greatest threat in patients with head and neck injuries. The jaw-thrust and chin-lift maneuvers (Fig. 1.1) are the simplest means of stabilizing the airways.

Foreign bodies (dentures, mucus, and vomitus) must be removed from the oral cavity using a finger. More proximal airways should be cleaned by suction if possible.

Intubation with pharyngeal tubes is another possibility for securing the airways (Guedel tube, Wendel tube; Fig. 1.1c). For complex injuries, transport to a regional trauma center is essential. If associated injury of the neurocranium is suspected, early orotracheal intubation should be performed.

Stabilizing Circulation

It is imperative that treatment of shock begin at the scene. Initial management includes:

elevation of the patient's legs (autotransfusion);

intravenous administration of a colloidal volume substitute;

adequate pain management;

protection from hypothermia.

Massive hemorrhage should be managed with direct compression. Ligation of the extremities should be avoided, however, and the exact time that compression began must be noted. Cardiopulmonary resuscitation should be performed if necessary.

Emergency Care

Soft tissue injuries should be covered with a sterile bandage to help control bleeding and protect the wound from additional contamination. Penetrating foreign bodies should be removed only after the patient is in a clinical setting.

If cervical spine injury is suspected, rotation or hyperextension of the patient's neck must be avoided. If removal of a motorcycle helmet at the scene is necessary in order to control the airways, a second person must stabilize the cervical spine using traction. Then, a rigid cervical collar must be applied until cervical spine injury has been excluded.

After emergent care procedures are complete, further treatment should take place in a specialized properly equipped trauma center. This is especially important for complex injuries. The patient should only be moved after stabilization of vital functions.

Fig. 1.1 Obstruction of the upper airways caused by fall-back of the tongue and epiglottis (modified from Eisele and McQuone 2000).

a Laxity of the tongue musculature causing it to obstruct the upper airways.

b Tilting the head to dorsal and applying pressure to the chin assures the patency of the airways.

c Positioning a Guedel tube to secure the upper airways.

Emergency Measures

Airways

Establishment and maintenance of the airways is of the utmost urgency in treating any multiply injured patient with craniofacial trauma. It is important to remember that following an accident, even airways with adequate ventilation can quickly become obstructed by blood or swelling.

Fall-Back of the Tongue

A particular problem of craniofacial injury is the fall-back of the tongue in segmental fractures of the mandible, especially those involving the midface. The continuity of the horseshoe-shaped mandible, to which the tongue is attached, is disrupted and the injured individual is no longer able to maintain the position of the tongue to keep the airways open (Fig. 1.2).

In an emergency, one can attempt to place the patient in the lateral position or to advance the fractured mandibular arch manually. If the patient is unconscious, a suture can be placed through the posterior of the tongue, lifting the tongue and pulling it forward (Fig. 1.2c).

Oral intubation follows. Successfully positioning the larynx is usually unproblematic, despite hemorrhage and swelling, as the tongue base loses its supporting buttress as a result of mandibular injury.

Fig. 1.2 Obstruction of the upper airways in a mandibular fracture.

a Dorsal displacement of the mandibular arch and tearing of the musculature of the floor of the mouth and tongue.

b Fall-back of the tongue due to loss of fixation on the mandible.

c Emergency procedure for advancing the tongue using a suture to establish the airways.

Injuries of the Larynx and Trachea

Specific problems related to injury of the larynx and trachea can arise and should be expected:

Extensive injury of the larynx often renders oral intubation impossible; intubation should never be forced under such circumstances as manipulation can permanently obstruct any remaining space in the larynx. In rare cases, intubation can be attempted using a stiff tube.

In an emergency, tracheotomy is always preferable to intubation.

Cricothyrotomy is not advisable due to possible existing concomitant injury of the cricoid cartilage or cricoid lamina.

In penetrating injuries of the trachea or larynx, the injury site should be used for intubation (Fig. 23.2a, p. 208).

If tracheal rupture is suspected, intubation should be accomplished using a flexible endoscope or by means of primary tracheotomy. The endoscope is advanced under visualization past the tracheal injury and the tube is positioned inferior to the injury site. The tube should not be too large as this can result in further displacement of the ruptured trachea (Fig. 14.5, p. 126).

Cricothyrotomy

Cricothyrotomy involves creating an opening in the cricothyroid membrane, which covers the area between the thyroid lamina and the cricoid cartilage. The emergency cricothyrotomy kits available today belong to standard paramedic equipment:

The cricoid cartilage is palpated and the slight indentation above it is punctured with a needle.

If the needle comes into contact with the thyroid cartilage, it can be used to guide the needle to the cricothyroid membrane. The needle tip then points in the direction of the jugular and is directed downward to the palpable gap and then advanced through the cricothyroid membrane (Fig. 1.3).

If an emergency kit is not available, a horizontal incision is made over the cricothyroid membrane. A blade with suitable dimensions is advanced directly into the trachea. The blade is not removed, but instead is rotated, thus serving to guide a speculum or catheter for placing the tube.

Fig. 1.3 Cricothyrotomy (modified from Eisele and McQuone 2000).

a Palpation of the cricoid cartilage; an incision is made at its superior border.

b A suitably sized blade is used to penetrate the cricothyroid membrane and is advanced in the trachea, where it is then rotated.

c Intubation occurs through the opening created into the trachea.

Following cardiopulmonary resuscitation, a cricothyrotomy should be transformed into a tracheotomy as it will otherwise result in permanent damage to the larynx after a few days.

Tracheostomy

Procedures for tracheostomy are similar to those used in cricothyrotomy. Emergency kits are also available for urgent tracheostomy.

If possible, a local anesthetic (e. g., lidocaine with epinephrine to control bleeding) should be applied prior to beginning the procedure.

An incision is then made in the skin vertically (minimizing the risk of damage to the thyroid gland), directly into the trachea.

The blade remains in situ, and a speculum is inserted over it; the opening is enlarged and a tube is advanced (Fig. 1.4). If necessary, a suction catheter can also be inserted in order to advance the tube using the Seldinger technique.

Given the consequences of respiratory insufficiency, concerns about heavy bleeding are misplaced. In most cases, hemorrhage can be controlled using a clip or by means of compression, for example, damp packing in the tube until definitive treatment (tracheostomy).

Definitive treatment, i. e., tracheostomy, must be assured.

Fig. 1.4 Tracheotomy (modified from Eisele and McQuone 2000).

a One hand stabilizes the larynx while a vertical incision is made in the skin beneath the cricoid cartilage.

b The tissue is forced apart using the fingers until the trachea can be seen.

c Opening of the trachea with a longitudinal incision.

d Inserting the tube, if necessary using a catheter or with the aid of a speculum.

Fig. 1.5 Course of arteries in the central midface.

Hemorrhage

Head and neck hemorrhage can quickly become life-threatening due to blood loss, but also due to aspiration.

In many cases, emergency management of hemorrhage is possible after identifying the bleeding vessel. If bleeding cannot be controlled, selective angiography and embolization are needed. Hemorrhage in the head and neck region can be divided into central and peripheral bleeding.

Central Hemorrhage

Central hemorrhage describes bleeding from vessels which are inaccessible for direct treatment, for example, compression, because of their anatomic position.

Maxillary Artery

The maxillary artery is the most commonly affected vessel. In midfacial fractures, it is generally injured in the pterygopalatine region, whereby the sharp edges of the bone at the fracture site between the posterior wall of the maxillary sinus and pterygoid process rupture the vessel wall (Fig. 1.5). Additional hemorrhage arises from the accompanying venous plexus. Blood is lost either directly or through the maxillary sinus and then from the nose or throat.

Nasal packing, part of emergent care, widens existing fracture gaps and thus increases bleeding. Only by fixing the maxillary bone segment and compressing it against the skull base can sufficient stability for packing be achieved.

A head/chin strap (Fig. 1.6) can be applied for stabilization at the scene of the accident, usually after intubation. A gauze bandage is used to press the mandible against the skull base and then the nose is packed.

For delayed intubation, compression can also be achieved by applying a spatula bandage, which uses a gauze bandage to press a wooden spatula, which has been inserted into the patient's mouth, against the skull base (Fig. 1.6a).

If bleeding does not cease using the measures mentioned here, occlusion of the artery by means of selective angiography (Fig. 1.7) is recommended for achieving definitive control of bleeding. In some circumstances, ligation of the artery after it branches off of the external carotid artery may be considered. Transantral ligation is generally very difficult.

Anterior and Posterior Ethmoid Arteries

Hemorrhage from the ethmoid arteries can usually be managed using anterior nasal packing (see Fig. 1.8). Additional posterior packing is rarely necessary.

Injury to the anterior ethmoid artery causing the vessel to recede into an orbit with intact orbital cone can cause intraorbital hemorrhage and compression of orbital contents. Clinical signs of orbital compression are subconjunctival hemorrhage with chemosis and a bulging globe. The orbit should be decompressed immediately by lateral canthotomy (Fig. 20.1, p. 180).

For persistent bleeding, occlusion of the vessels may be necessary from an external or through an endonasal approach.

Carotid Artery

Hemorrhage from the carotid artery near the cranial base is usually fatal. In a limited number of cases, immediate tamponading of the epipharynx (Bellocq packing, Fig.1.9, p. 10) can control bleeding. However, the consequences, such as spreading of the hemorrhage upward in the neurocranium or vasospasms, generally are fatal.

In an emergency, an attempt can be made at stopping carotid hemorrhage by applying pressure over the sixth cervical vertebra. This is best done from a kneeling position over the patient by intermittently pressing one's full body weight onto a closed fist held against the vertebrae.

Anterior Nasal Packing

Anterior nasal packing involves tamponading the nose through the front opening using ready-made foam rubber packs, which are available in various sizes, or Vase-line gauze packing. Nasal balloons that can be filled with fluid are also available (see Fig. 1.9e).

Anesthetization of the nose with a spray or wadding soaked in local anesthetic and naphazoline nitrate is helpful. Always insert packing over the floor of the nose.

Nasal packing must be secured using a tie which is fixed externally with adhesive tape.

Fig. 1.6 Head bandages for compression of the maxilla to control hemorrhage (modified from Schwenzer and Ehrenfeld, Vol. 2, 2002).

a Craniomaxillary suspension of the maxilla using gauze bandages and wooden spatulas.

b Maxillary splint or dental impression tray can be secured with an extraoral brace secured by a head bandage.

Fig. 1.7 Selective angiography in maxillary artery hemorrhage which could not be controlled conservatively.

a Computed tomography image of injury of the facial skeleton.

b Selective angiography showing hemorrhage from the right maxillary artery.

c Cessation of bleeding after occlusion of the maxillary artery.

Bellocq Packing

Bellocq packing involves anterior and posterior packing of the nasal cavity:

Tamponading begins with posterior packing: Either fluid-filled (sodium chloride) catheters (bladder catheter, etc.) (Fig. 1.9a) or cotton ball packing may be used. Cotton ball packs have three securing ties. The pad, which has two ties secured to the end of a narrow catheter (gastric tube, suction catheter), is advanced through the mouth into the epipharynx (Fig. 1.9b). The position of the pack should be checked digitally to ensure that the soft palate and uvula are not crushed (Fig. 1.9c).

Anterior nasal tamponading can then proceed, accompanied by continuous traction on the ends of the strings.

Fixation is completed under traction, placing a pad at the opening of the nose (Fig. 1.9d). The third string is retracted through the mouth and taped to the patient's cheek for later removal of the pack.

Nasal packing should never remain in place longer than three days. Irreversible damage to the nasal mucosa can otherwise result.

Fig. 1.8 Anterior nasal packing (modified from Fonseca et al. 1997).

a The procedure begins on the floor of the nose with multi-layered Vaseline gauze packing. Holding the packing 5–6 cm from its end, it is placed as deep as possible in the nasal cavity.

b Layers of the gauze pack are positioned layer by layer until the nasal cavity is filled.

Peripheral Hemorrhage

Peripheral hemorrhage usually involves the large branches of the external carotid artery (temporal artery, facial artery, lingual artery). Direct injury—missile wound or penetrating trauma—of the common carotid artery may occur in rare cases.

Initial management should always seek to control bleeding with compression by pressing the vessels against underlying skeletal structures:

temporal artery against the root of the zygomatic arch;

facial artery against the anterior edge of the mandible, at the anterior margin of the attachment of the masseter muscle;

lingual artery with bi-manual pressure exerted intra-orally and extraorally;

carotid artery against the sixth cervical vertebra.

Hemorrhage of this type should be treated as quickly as possible with definitive surgical management, locating and ligating visible vessels. Injury to the great vessels of the neck demands immediate reconstruction with direct vascular suture, management with a patch graft, or vascular prosthesis.

Fig. 1.9 Bellocq packing.

a A bladder catheter may be used for emergency closure of the epipharynx.

b A gauze pad is normally drawn into the epipharynx over a suction catheter.

c The position of the packing in the throat must be checked with a finger.

d Using steady traction on the Bellocq tampon, anterior nasal packing is then placed. Finally, a pad is knotted over the nasal opening using the strings from the Bellocq tampon for the purpose of maintaining traction on the epipharyngeal packing.

e Alternatively, specially made packing, which can be filled with water, can be used.

Priorities in Trauma Management

Table 1.1 lists the various phases in the care of trauma victims.

After eliminating acute, life-threatening risks and preparing the patient for surgery, initial management can begin. Urgent immediate care should be given to the following:

hemorrhage;

orbital and optic nerve injuries with risk of vision impairment or blindness;

mobile, open jaw fractures;

soft tissue injuries.

Initial management is not necessarily the definitive treatment. After stabilizing the patient, completing diagnosis, planning of interventions, and subsidence of swelling, definitive treatment can generally proceed after 5–8 days.

Table 1.

1

Essential steps in the care of trauma victims

Phase

Description

Resuscitation

Stabilization and restoration of vital functions

First operation

Urgent initial management

Stabilization

Intensive care, more detailed diagnosis, preparatory measures

Second operation

Definitive treatment of injuries

Rehabilitation

Rehabilitation, physical therapy

Third operation

Secondary corrective measures

2 Examining the Patient

Standardized evaluation procedures for all organ systems of the head and neck should be followed for every patient presenting with head trauma. Systematic evaluation minimizes the risk of overlooking any aspect of injury.

Patient History

Determining the mechanism of injury is paramount (e. g., see Table 2.1). If the patient is unconscious or unable to answer questions, witnesses to the accident, prehospital emergency care providers, and relatives should be interviewed. It is important to know the direct mechanism of injury as well as other factors (helmet, seatbelt, etc).

Knowing the patient's prior health status is vital. Special consideration should be given to:

pre-existing conditions;

previous operations;

infectious diseases (hepatitis, HIV);

immunization status (tetanus, rabies for animal bites).

Thorough documentation of patient history is also essential for follow-up insurance questions. Photo documentation is advisable.

Table 2.

1

Diagnosis and treatment required for various types of injury

Type of injury

Diagnosis

Treatment

Cut

p. 27

p. 131

Bite

p. 28

p. 131

Missile wound

p. 28

p. 135

Burn

p. 29

p. 133

Chemical/alkali burn

p. 30

p. 134

Inspection

Inspection involves assessing external injuries such as bruising, hematomas, and wounds. Even apparently insignificant injuries can be critical:

hemorrhage (Chapter 1, p. 6);

wounds (Diagnosis, Chapter 4, p. 27; Treatment, Chapter 15, p. 130);

foreign bodies;

hematomas.

Palpation

Palpation should always be carried out using a systematic approach (Fig. 2.1a). The aim of palpation is to detect swelling, hematomas, crepitus, and abnormal mobility. Palpation should be conducted bilaterally, using both hands.

Neck: Beginning at the jugular, the anterior of the neck is evaluated. After exploring the posterior neck, palpation then continues over the posterior head to the forehead.

Ear: Evaluation of the external ear. It is important to distinguish between hemorrhage coming from the auditory canal and bleeding into the auditory canal.

Orbits: Beginning at the superior orbital cavity, palpation proceeds over the lateral orbits, the infraorbital ridge to the medial orbits (Fig. 2.1b).

Mandible: The mandible is evaluated from the tip of the chin, over the mandibular angle to the condyles (auditory canals). Pain upon compression at the chin point is a sign of injury involving the temporomandibular joint region (Fig. 2.1c).

Temporomandibular joint: The little fingers are inserted into the external auditory canals and the patient is instructed to open the mouth. The condyles of the temporomandibular joint are palpated. Special consideration should be given to deviation of the mandible from its central position with opening of the mouth, as a sign of fracture (Fig. 2.1d).

Oral vestibule: The right mandibular oral vestibule is palpated to the mandibular arch, over the maxillary vestibule, and downward again over the left mandible. Special attention should be paid to injured teeth (Fig. 2.1e). Tapping the maxillary teeth of a healthy, nonfractured maxilla with a metal spatula produces a ringing sound. Fracture results in a reduced sound (bandbox resonance).

Fig. 2.1 Standardized evaluation procedures.

Palate: Maxillary mobility is evaluated by palpating the jaw, not the teeth. Disruption of the bony palate is a sign of sagittal fracture. See below for the various levels of mobility of the maxilla:

– Le Fort I level: The mobility of the maxilla in the Le Fort I level is evaluated by placing a finger on the pyriform aperture or the zygomaticomaxillary buttress while gently rocking the maxilla back and forth.

– Le Fort II level: A finger is placed on the inferior orbital rim at the height of the infraorbital foramen to test the mobility of the maxilla in the Le Fort II level (Fig. 2.1f).

– Le Fort III level: Maxillary mobility in the Le Fort III level can be evaluated by placing a finger on the zygomaticofrontal suture (Fig. 2.1g).

Functional Testing

Various functional tests should be performed following palpation. These must be modified according to the patient's pattern of injury and level of consciousness.

Eye: Pupil size and reaction must always be evaluated. If there is a unilaterally wide-open pupil without direct—but with indirect—light response, this is known as an amaurotic (fixed) pupil and must be further evaluated (see Fig. 10.8, p. 93). Preliminary vision testing should be performed and the motility of the globe in the main gaze positions (finger perimetry) checked. Special attention should be paid to double vision (Fig. 2.2).

Facial nerve: Coordination of movement in basic facial expressions is tested with brow elevation, eye closure, and pursing of the lips. In comatose patients transcranial nerve stimulation can be used.

Occlusion: Active or passive movement of the mandible toward the maxilla is used to test occlusion. Malocclusion appears as:

– anterior open bite (Fig. 11.15b, p. 110);

– malocclusion of the lateral incisor region (Fig. 11.16a, p. 111) or;

– edge-to-edge bite.

Fig. 2.2 Orientation of the eye in the six diagnostic positions of gaze (from Schwenzer and Ehrenfeld, Vol. 1, 2000). The main muscles responsible for movement are shown here.

Trigeminal nerve: Sensory disturbances of the trigeminal nerve distribution area can be observed to varying degrees: hypesthesia, anesthesia, and paresthesia. A cotton swab is used to test sensation in the region being evaluated, by moving it from the periphery toward the center, to the foramen, comparing the sensitivity of both sides.

Dental vitality test: Tooth vitality can be evaluated using a thermal test to look for a pain reaction of the dental pulp (see Fig. 12.2, p. 114). A cold aerosol spray is applied to the enamel surface using a cotton swab.

Auditory tests: Initial auditory tests can be performed using the tuning fork method based on Weber and Rinne (see Functional Testing of the Auditory and Vestibular System, p. 61).

Olfactory ability: Olfactory ability can be roughly checked using gasoline (see Clinical Signs Skull Base Injury, p. 48).

Radiologic Diagnostics

Radiographic evaluation should always be complementary to clinical diagnostics and should never serve as a substitute. Only after clinical examination can a reasonable decision be made regarding the required extent of imaging.

If midfacial fracture is suspected, the following are advisable:

occipitomental and eccentric cranial views (Fig. 9.17c, p. 84)

bucket handle view (see Fig. 9.18, p. 84)

For injuries of the mandible and temporomandibular joints, the following conventional radiographs are recommended:

orthopantomogram (OPG/OPT) (Fig. 11.5b, p.101)

view based on Clementschitsch (Fig. 21.9a, p. 194)

In addition, occlusal views, oblique mandibular projections, and dental radiographs may be advisable.

Computed tomography (CT) evaluation of craniofacial injury is standard these days and is mandatory, especially for complex patterns of injury. Moreover, 3-D imaging can be useful for planning reconstruction (Fig. 1.7, p. 8). For craniofacial views, 3 mm slices, in axial and coronal planes, are preferred; for petrous temporal bone fractures 2 mm slices are appropriate.

Angiography should be performed if there is unexplained hemorrhage; embolization, if needed, should be done in the same session (Fig. 1.7, p. 8). Magnetic resonance imaging (MRI) is only rarely indicated, for example, to search for cerebrospinal fluid fistulas (Fig. 6.5c, p. 51) or in injury to orbital contents.

3 Flow Charts and Checklists

Initial Management

See p. 2.

Table 3.

1

Checklist for initial management

Objective

Measure

Establish and maintain airways (intubation, cricothyrotomy, tracheotomy)

Clearing the upper airways of discharge or prolapsed tongue (combination fractures of mandible and maxilla), dentures

Stabilize circulation

Establishing intravenous access, monitoring, fluid resuscitation

Exclude intracerebral pressure, intracranial hematoma, brain swelling

Neurologic status, CT, possibly intracranial pressure (ICP) catheter, decompression, hematoma evacuation

Exclude internal bleeding

Thoracic trauma: CT, drainage if necessary

Abdominal trauma: ultrasonography, CT, or peritoneal lavage, laparotomy if necessary

Pericardial packing: ECG, echo-cardiogram, pericardiocentesis

Exclude paraplegia and compartment syndrome

Neurologic status, CT, decompression and stabilization of the spine if necessary

Clinical signs, sensation, motor response, fasciotomy if necessary, fracture reduction, osteosynthesis

Soft tissue injuries

Wound management

Initial Evaluation

Table 3.

2

Checklist for initial evaluation

Patient history

Loss of consciousness, vomiting

Impaired nasal breathing, loss of olfactory/taste sensation, impaired vision, sensory disturbance

Inspection and palpation

Hemorrhage, open wounds, foreign bodies

Cerebrospinal fluid or brain matter leak

Swelling, hematoma, air crepitus

Osseous step-offs, osseous gaps, abnormal mobility

Functional testing

Visual function

Taste sensation/olfactory function

Sensory assessment

Diagnostic imaging

CT, a.-p. cranial views, lateral cranial views

Immediate care

Extruding brain matter, intracerebral hemorrhage, intracerebral pressure, vision loss

Interval treatment

Cerebrospinal fluid leak, pneumocephalus

– Orbit and globe

Pupil width and reaction, gross evaluation of vision, globe position, motility, diplopia

Diagnostic imaging

Radiologic evaluation of the paranasal sinuses, compare zygomatic arches, OPG, Clementschitsch, CT

Immediate care

Replantation of teeth

Management of open fractures

Interval treatment

Craniofacial reduction and reconstruction

Injuries of the Neurocranium

Diagnosing Injuries of the Neurocranium, Chapter 5, p. 38.

Treatment of Injuries of the Neurocranium, Chapter 16, p. 137.

Fig. 3.1 Flow chart for acute head injury.

Injuries of the Skull Base

Diagnosing Injuries of the Skull Base, Chapter 6, p. 45.

Treatment of Injuries of the Skull Base, Chapter 17, p. 140.

Fig. 3.2 Flow chart for injuries of the skull base.

Injures of the Ear and Lateral Skull Base

Diagnosing Injuries of the Ear, Chapter 7, p. 53.

Treatment of Injuries of the Ear, Chapter 18, p. 147.

Fig. 3.3 Flow chart for injuries of the ear.

Table 3.

3

Checklist for injuries of the ear and lateral skull base

Patient medical history

Impaired hearing, tinnitus, dizziness

Inspection and palpation

Facial asymmetry due to swelling or palsy

External ear: hematoma, open wounds, cartilage injuries, bone gaps, step-offs

Auditory canal: temporomandibular joint (terminal occlusion and articular motion)

Otoscopy, micro-otoscopy

Bleeding from the middle ear with auditory canal and tympanic membrane injuries, exclude external hemorrhage

Ascending and pulsating CSF or extruding brain matter

Posterior auditory canal step-off (longitudinal petrous temporal bone fracture)

Anterior auditory canal step-off (temporomandibular joint fracture)

Intact tympanic membrane and hemotympanum (transverse petrous temporal bone fracture)

Hearing test

Tuning fork tests (Weber, Rinne)

Liminal audiogram

Balance test

History of vertigo

Frenzel goggles (spontaneous nystagmus, position testing, positional testing)

Coordination tests (Unterberger test, Romberg test)

Diagnostic imaging

CT petrous temporal bone

Table 3.

4

Checklist for injuries of the facial nerve

Patient medical history

Pre-existing palsy

Inspection

Voluntary motor function, comparing sides of facial expression musculature

Functional testing

Diagnostic localization of nerve injury, EMG

Radiologic diagnosis

CT petrous temporal bone

Immediate management

Uncontrollable hemorrhage from the ear

Sudden palsy of the facial nerve (in the first 48 hours)

Interval treatment

Persistent or increasing facial nerve palsy

Conductive hearing loss

Injuries of the Facial Nerve

Diagnosing Injuries of the Facial Nerve, Chapter 8, p. 64.

Treatment of Injuries of the Facial Nerve, Chapter 18, p. 153.

Craniofacial Injuries

Diagnosing Injuries of the Midface, Chapter 9, p. 69.

Diagnosing Injuries of the Mandible, Chapter 11, p. 96.

Treatment of Injuries of the Midface, Chapter 19, p. 157.

Treatment of Injuries of the Mandible, Chapter 21, p. 186.

Fig. 3.4 Flow chart for injuries of the facial skeleton.

Table 3.

5

Checklist for craniofacial injuries

Patient medical history

Trismus, lockjaw, pain (articular movement), impaired nasal breathing, vision impairment, sensory disturbance

Inspection and palpation

Facial asymmetry

– extraoral

Hemorrhage and open wounds, perforations, swelling, hematoma

Tenderness, osseous step-offs, bone gaps

– intraoral

Hemorrhage, hematoma, osseous step-offs, gingival injury, gingival hematoma

Dental fractures, dental luxation

– combined extraoral and intraoral

Abnormal midfacial mobility

Rhinoscopy

Mucosal tears, hemorrhage, septal fracture, CSF leak

Functional testing

Jaw percussion, sensory/viability test of the teeth, occlusion, olfactory test

Injuries of the Orbits

Diagnosing Orbital Injuries, Chapter 10, p. 86.

Treatment of Orbital Injuries, Chapter 20, p. 179.

Fig. 3.5 Flow chart for orbital injuries.

Table 3.

6

Checklist for orbital injury

Patient medical history

Vision impairment, visual field dysfunction, loss of vision, double vision, sensory disturbance

Inspection and palpation

Bleeding and open wounds, impacted or embedded foreign bodies, swelling, hematoma, air crepitus

– eyelids and conjunctiva

Lid margin, canaliculi, cannulation/irrigation of lacrimal drainage ducts

– orbital rims

Step-offs and gaps, mobile or displaced fragments

– globe

Foreign bodies, enophthalmos, exophthalmos, chemosis, pulse synchronous noise

Functional testing

Vision, visual acuity

Pupil width and pupil response

Globe mobility

Diagnostic imaging

Craniofacial CT

Immediate management

Orbital decompression

Optical nerve decompression

Globe injury

Reconstruction of lid and lacrimal ducts

Interval treatment

Orbital reconstruction

Dental Injury

Diagnosing Dental Injuries, Chapter 12, p. 112.

Treatment of Dental Injuries, Chapter 22, p. 199.

Table 3.

7

Checklist for dental injuries

Broken tooth

Early initiation of treatment for pain or markedly increased sensitivity to hot and cold

– enamel infraction and enamel/dentin injury

Begin therapy within 12–48 hours

– fracture with opening of the pulp

If pulp exposure, tooth hemorrhage results. Therapy within 24 hours.

– root fracture

Dental luxation

Replant tooth in original position if possible

Begin therapy immediately

Immobilization is a must

Tooth avulsion

Imperative to avoid dehydration of the periodontal ligament cells. Ideally replant tooth in socket within first 15–20 min.

If not possible, tooth must be kept in a moist medium: fluid container (tooth preservation box); oral vestibule, caution with small children due to risk of choking; milk; water.

Emergency splinting

Aluminum foil splint, pressed over the luxated tooth and at least two neighboring teeth: remains until quickest possible definitive treatment

Injuries of the Neck

Diagnosing Injuries of the Larynx and Trachea, Chapter 14, p. 121.

Treatment of Injuries of the Larynx and Trachea, Chapter 23, p. 205.

Fig. 3.6 Flow chart for injuries of the neck.

Table 3.

8

Checklist for injures of the neck

Patient history

Pain on swallowing, inability to swallow, coughing, respiratory distress, loss of voice

Inspection and palpation

Inspiratory stridor, deep jugular or intercostal depression

Open wounds, bleeding, saliva leak

Swelling, hematoma, tenderness, crepitus, air crepitation

Functional testing

Voice for hoarseness or aphonia

Swallowing ability

Endoscopy techniques

Transnasal pharyngolaryngoscopy

Suspension laryngoscopy

Tracheobronchoscopy: mucosal tear, free cartilage ring, arytenoid cartilage dislocation, vocal fold immobilization

Diagnostic imaging

Thorax, soft tissues of the neck, CT

Immediate management

Cricothyrotomy, tracheostomy, treat open wounds

Interval treatment

Definitive treatment