gsws to max fac region

Gunshot Injuries to Max-Fac Region

Dr. Khadim ShahT.M.O

• Management of gunshot injuries to the face led in many ways to the development of modern maxillofacial surgery, and it remains a cornerstone of the specialty of oral and maxillofacial surgery.

Firearm injuries

Firearm injuries

Firearm injuries

Firearm injuries

Handguns87%

Shotguns8%

Rifles5%

Civilian Injuries

Handguns Shotguns Rifles

Multiple Sites

Maxilla Mandible Orbit0%

5%

10%

15%

20%

25%

30%

26%

14% 13%

9%

Sites Involved

BallisticsBallistics is the science of projectile motion.• deal with the flight, behavior, and effects

of projectilesBallistic science is typically divided into three

stages:Internal BallisticExternal BallisticTerminal Ballistic

Ballistics

Internal Ballistics

Ballistics

External Ballistics

Ballistics

Terminal Ballistics

Classification of Gunshot Injuries

Low velocity • ( < 350 m/s )

Intermediate velocity • (350–600 m/s)

High velocity • (> 600 m/s)

Classification of Gunshot Injuries

Gugala and Lindsey Classification

• Energy• Involvement of vital structures• Wound type• Fracture and• Contamination

Handguns

Handguns

Rifles

Rifles

Types of Missile Wound

•Non-penetrating: • Penetrating:• Perforating:•Avulsive:

•Non-penetrating• grazing or blast

wound

Types of Missile Wound

• Penetrating: • low impact

velocity, bullet does not exit

Types of Missile Wound

• Penetrating: • low impact

velocity, bullet does not exit

Types of Missile Wound

Types of Missile Wound

• Penetrating: • low impact

velocity, bullet does not exit

• Penetrating: • low impact

velocity, bullet does not exit

Types of Missile Wound

• Perforating: • High velocity ,

bullet in and out

Types of Missile Wound

Types of Missile Wound

• Perforating: • High velocity ,

bullet in and out

•Avulsive: •Massive wounds

with avulsion and loss of tissues

Types of Missile Wound

Types of Missile Wound

•Avulsive: •Massive wounds

with avulsion and loss of tissues

Mechanism of GSW

Mechanism of GSW

Management of gunshot wounds :

Airway•Remove any foreign bodies

or loose teeth.

Airway•Remove any foreign bodies

or loose teeth.•Head tilt/Chin lift

Airway•Remove any foreign bodies

or loose teeth.•Head tilt/Chin lift• Jaw thrust

Airway•Remove any foreign bodies

or loose teeth.•Head tilt/Chin lift• Jaw thrust•Endotracheal Tube

Airway•Remove any foreign bodies

or loose teeth.•Head tilt/Chin lift• Jaw thrust• Endotracheal Tube•Upper Airway Bypass

Hemorrhage Control

Direct pressure and packing. Epistaxis control. Temporary reduction of the fracture.ThermocoagulationLigation

Fluid Resuscitation

•Maintain an IV Line

• Infuse Crystalloids 3 ml for every 1 ml Blood loss

•Need for Colloids, FFP, Blood

Secondary Survey

Physical Examination:•Head to toe examination•Assessing facial soft tissue status• Sensory disturbances.•Motor nerve deficits. •Ocular and orbital injury. •Oral cavity examination is crucial.

Consultation

•Ophthalmology•Neurosurgery• ENT•General Surgery•Any other as indicated

Penetrating injury of the neck

•Zone I ; from the clavicles to the cricoid cartilage•Zone II ; from the cricoid cartilage

to the angle of the mandible.•Zone III ; from the skull base to

the angle of the mandible

Investigations•Conventional Radiographs•OPG (Orthopantomogram)

Investigations•Conventional Radiographs•OPG

(Orthopantomogram)• Lateral Cervical Spine

Investigations•Conventional Radiographs•OPG

(Orthopantomogram)• Lateral Cervical Spine•Chest X-ray

Investigations•Conventional Radiographs•OPG

(Orthopantomogram)• Lateral Cervical Spine•Chest X-ray•PA view of Mandible

Investigations•Conventional Radiographs•OPG

(Orthopantomogram)• Lateral Cervical Spine•Chest X-ray• PA view of Mandible•OMV

Investigations•Advance Imaging Technique• 3D CT Complex trauma

Investigations•Advance imaging technique• 3D CT Complex trauma•Barium Swallow/Endoscopy

Esophageal injury

Investigations•Advance imaging technique• 3D CT Complex trauma•Barium Swallow/Endoscopy

Esophageal injury•CT angiography / Angiography

Vascular injury

Investigations•Advance imaging technique• 3D CT Complex trauma•Barium Swallow/Endoscopy

Esophageal injury•CT angiography / Angiography

Vascular injury

•Routine Lab Investigations

Treatment Planning

• Patient Counselling / Psychological Support• Informed Written Consent• Treatment options with outcome•Need for multiple surgeries

•Anesthetist Consultation

Primary Surgery

A)Debridement of the wound :Convert a crushed wound into an incised

wound Vigorous irrigationSmall completely detached pieces of bone

better to be removed.All pieces with any viable soft tissue

attachment should be conserved

B)Management of injury to important structures :

NervesMicroneurosurgical repair orTag both ends of nerves with

non-resorbable suture with early secondary repair (3-4 weeks)

Parotid duct and glandDuct repair over small silicon

tube & leave stent there in place for 4-6 weeks

Management of Skin Loss• If skin loss (< 2 cm) it should be

reconstructed by undermining

• If more ( > 2 cm ) it is managed by :•Dressing to promote epithelialisation•Covered by split thickness skin graft • Local flaps•Regional flaps • Free flap

Post Operative Care• Vital Signs Monitoring

• Diet and feeding

• Liquid diet •Nasogastric tube can be used in extensive

injury• Saliva shield made of acrylic or silicon can

be used• Gastrostomy if long term bypass of the

oral cavity is necessary

Post Operative Care•Oral hygiene •Mouth wash with antiseptic

solution• Irrigation•Brushing• 1% hydrocortisone ointment

•Control of infection• Prophylactic antibiotics• Early mobilization

(contd)

Follow Up

•Both Clinical and Radiographic•Residual deformity• Soft tissue•Hard tissue

•Ocular examination•Mouth opening

Follow Up

•Nutrition and speech• Psychological status/support•Management of complications• Infection•Malunion or non union•Malocclusion• Facial nerve paralysis etc

(contd)

Secondary Revision Surgery•Residual Deformity• Functional•Cosmetic

• Trismus• Flap Debulking• Scar Revision•Vestibuloplasty•Dental Rehabilitation

Avulsive Injury

Pre-OperativePrimary Surgery

Second Surgery

Summary

• 2nd most common source of death•ATLS protocol•Debridement Fracture Stabilization

Primary closure•Reconstruction•Rehabilitation

References

• http://crss.pk/story/6229/pakistan-conflict-tracker-monthly-report-may-2014/• Rowe and williams maxillofacial injuries• PETERSON'S PRINCIPLES OF ORAL AND

MAXILLOFACIAL SURGERY Second Edition• Articles from internet

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