Maxillofacial Trauma August 19, 2010 Jay Green Colin Del Castilho
Intro Soft tissue injuries – Case work – Case discussion – Regional anesthesia Bone/joint injuries – Case work – Case discussion
Intro stuff
Soft tissue injury cases
Case 1 48y male, intoxicated Fell striking cheek on the bar Laceration to anterior cheek Through-and-through
Case 2 18y hockey player “Too good” to wear a face mask High stick to the face Upper lip laceration Crosses vermillion border Involves muscular layer
Infraorbital nerve block
Case 3 25y female MVC, ejected Intubated by STARS on scene Swelling facial and periorbital Extensive abrasions to forehead with gravel/glass in wound
Ophthalmic (V 1 ) nerve block
Case 4 It’s June 28, y male boxer Lac to right ear during fight Through cartilage Claims he was bitten Opponent says it was a punch
Ear field block
Case 5 12y female Skateboarding for the first time Fell Caught tongue between teeth Tongue laceration
Indications for tongue laceration repair (controversial) Midline Need hemostasis Large flap (>1cm or gaping) Avulsion/amputation Nonlinear laceration or U-shaped emedicine, EM Clinics of North America, Roberts & Hedges, Rosen
Inferior alveolar/lingual nerve block
Soft Tissue Injuries Questions?
Additional questions Q) What are indications for abx in facial trauma Bite wound Devascularized tissue Through-and-through buccal mucosa Cartilage involvement (nose/ear) Extensive contamination Open # # into sinus # with CSF leak
Additional questions Q) What is appropriate mgmt of pediatric peri-oral electrical burns? What is the concern here? Can result in severe cosmetic issues and microstomia Trivial looking initial wound may progress over days 5-21 days post-burn get eschar separation and can have lift-threatening labial artery bleeding NEED TO D/W plastics in the ED! Can d/c home with close watching and F/U ENT/plastics if not extensive initially Options: early surgery, oral splinting, delayed surgery
Additional questions Q) Management of subperichondral hematoma? Risk factor for cauliflower ear Needs needle aspiration Compressive dressing R/A in 24hrs to ensure hematoma has not re- accumulated
Additional questions Q) Describe appropriate ED management of eyelid lacerations. Superficial lacs can be repaired with 6-0 Ethilon Lid margin, canalicular, lacrimal involvement need ophtho/plastics
Quick break
Case 6 It’s 0100 Dude and his girlfriend come in She was “yawning” and mouth got stuck open
Case 7 16y male Tough guy Punched in the nose Swelling to nasal bridge Crooked nose? Hard to tell…
Case 8 22y female Squash player Hit in eye by ball Diplopia on up-gaze CT shows orbital floor blowout # without entrapment of EOM
Case 9 Same polytrauma as Case 3 Still intubated Bleeding into oropharynx & nasopharynx from ? You think her face is mobile
Case 10 35y female, fell down stairs Teeth don’t fit right Neck pain, no c-spine # No other injuries
Bone/Joint Injuries Questions?