gsws to max fac region
TRANSCRIPT
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
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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