Tactical Emergency Medicine and Facial Trauma Eric Vaughan MD, FACEP Tactical Emergency Medicine and Facial Trauma Eric Vaughan MD, FACEP Clinical Assistant Professor Associate Director of EMS Department of Emergency Medicine University of Kansas Medical Center • ISTM and CONTOMS • Deployed Afghanistan and Europe supporting AFSOC, ARMY, and NATO Special Operations Command as an Emergency Medicine Physician • Critical Care Aeromedical Transport Team • Life Flight Physician • Army Medic • Lecture nationally and Internationally on Tactical Medicine • Developing an EMS fellowship at the University of Kansas • Developing Tactical Medical protocols as the Assistant Medical Director for Kansas Highway Patrol Tactical Teams • Affiliated Faculty for KCMTOA Annual TEMS training • Assistant Medical Director for KCK EMS.

OBJECTIVES

• Identify where traumatic facial in the field or tactical environment fit into the overall Tactical Combat Casualty Care (TCCC) model for trauma patient treatment and evacuation. • Discuss specific facial patterns and critical actions needed to provide optimal trauma care in the austere or tactical environment.

Etiology and Incidence

• More than three million facial injuries occur in the United States each year  Sports, accidental falls, motor vehicle accidents, assaults, and work-related accidents account for the majority  In a series of over 200 consecutive facial fractures seen in an urban , assaults accounted for nearly 50%.  The adult male to female ratio is 3:1.  Nasal and mandibular fractures most common in community ED’s Midface and zygomatic injuries most common in Trauma centers  25% of women with facial trauma result of domestic violence

Etiology and Incidence

• Among sport-related injuries, boxing and mixed martial arts are particularly associated with a high incidence facial injuries.

TCCC

• Originally a Special Operations research effort • Trauma management plans that take into account the unique challenges faced by combat medical personnel • Now used throughout U.S. military and by most allied countries • TCCC has helped U.S. combat forces to achieve the highest casualty survival rate in history. Three Objectives of TCCC

• Treat the casualty • Prevent additional casualties • Complete the mission Phases of Care in TCCC: Timing Is Everything • Casualty scenarios in combat usually entail both a medical problem as well as a tactical problem. • We want the best possible outcome for both the casualty and the mission. • Good medicine can sometimes be bad tactics; bad tactics can get everyone killed or cause the mission to fail. • Doing the RIGHT THING at the RIGHT TIME is critical TCCC Phases of Care

• TCCC divides care into 3 phases based on the tactical situation. – Care Under Fire – Tactical Field Care – Tactical Evacuation Care • During the gunfight, attention is focused primarily on eliminating the threat. • As the threat decreases, increasing focus is applied to providing the best possible medical care for the casualties. CARE UNDER FIRE Care Under Fire Guidelines

1. Return fire and take cover. 2. Direct or expect casualty to remain engaged as a combatant if appropriate. 3. Direct casualty to move to cover and apply self-aid if able. 4. Try to keep the casualty from sustaining additional . Care Under Fire Guidelines

5. Casualties should be extricated from burning vehicles or buildings and moved to relative safety. Do what is necessary to stop the burning process.

6. is generally best deferred until the Tactical Field Care phase. Care Under Fire

• If the firefight is ongoing - don’t try to treat your casualty in the Kill Zone! • Suppression of enemy fire and moving casualties to cover are the major concerns. Moving Casualties in Care Under Fire

• If a casualty is able to move to cover, he should do so to avoid exposing others to enemy fire. • If casualty is unable to move and unresponsive, the casualty is likely beyond help and moving him while under fire may not be worth the risk. • If a casualty is responsive but can’t move, a rescue plan should be devised if tactically feasible. The Number One Medical Priority in Care Under Fire

Early control of severe hemorrhage is critical. – Extremity hemorrhage is the most frequent cause of preventable battlefield deaths. – Over 2500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. – Injury to a major vessel can quickly lead to shock and death. – Only life-threatening bleeding warrants intervention during Care Under Fire. Airway – Will Cover in Tactical Field Care

No immediate management of the airway is anticipated while in the Care Under Fire phase. –Don’t take time to establish an airway while under fire. –Defer airway management until you have moved casualty to cover. –Combat deaths from compromised airways are relatively infrequent. –If casualty has no airway in the Care Under Fire phase, chances for survival are minimal. C-Spine Stabilization

Penetrating head and injuries do not require C- spine stabilization –Gunshot wounds (GSW), shrapnel in , the spinal cord is either already compromised or is in relatively less danger than would be the case with . –Only 1.4% would have benefited from C-spine stabilization TACTICAL FIELD CARE Tactical Field Care

• Distinguished from Care Under Fire by: –A reduced level of from hostile fire –More time available to provide care based on the tactical situation • Medical gear is still limited to that carried by the medic or corpsman or unit members (may include gear in tactical vehicles) Tactical Field Care

• May consist of rapid treatment of the most serious wounds with the expectation of a re-engagement with hostile forces at any moment, or • There may be ample time to render whatever care is possible in the field. • Time to evacuation may vary from minutes to several hours or longer. MARCH

• Massive hemorrhage – control life-threatening bleeding. • Airway – establish and maintain a patent airway. • Respiration – decompress suspected tension , seal open chest wounds, and support ventilation/oxygenation as required. • Circulation – establish IV/IO access and administer fluids as required to treat shock. • /Hypothermia – prevent/treat hypotension and hypoxia to prevent worsening of and prevent/treat hypothermia. Tactical Field Care Guidelines

Casualties with an altered mental status should be disarmed immediately. Maxillofacial Trauma

• Casualties with severe facial injuries can often protect their own airway by sitting up and leaning forward. • Let them do it if they can! Clinically Relevant Anatomy Clinically Relevant Anatomy

History & Physical

 Questions  Are there any areas of numbness  Inferior alveolar nerve runs through the center of the from the middle of the ramus to the mental foramen, where it exists to provide sensation to the lower lip and chin  Infraorbital and superior alveolar nerves provide sensation to the maxillary teeth and gingiva, the upper lip, the side of the nose, and the lower eyelid  Does your bite feel normal  Mandibular and/or maxillary fractures History & Physical

 Questions  Are there visual changes or difficulty seeing?  Retrobulbar , vascular occlusion, optic nerve contusion, retinal detachment vitreous hemorrhage. Other ophthalmologic conditions to include corneal abrasions, traumatic iritis, globe rupture, and lens dislocation.  Do you see double?  Periorbital fracture with or without impingement of the extraocular muscles History & Physical

 Physical Exam – The clinical examination of the begins with a detailed examination of the area for localized tenderness, numbness, bleeding, deformity, ecchymosis, periorbital edema, otorrhea, , and facial asymmetry  Examine the oral cavity – Closely examine the eyes, even if the eye is swollen shut – Midface stability should also be evaluated. This can be accomplished by grasping the teeth and hard palate and gently pushing back and forth and then up and down History & Physical

– Internal and external evaluation of the nose, regardless of the mechanism of injury • Examine the nose for CSF fluid and septal hematoma – Examine the mandible and TMJ, and utilize the tongue blade test • Have the patient grip a tongue blade with is/her teeth and then break it by twisting. This test has been shown to be 95.7% sensitive if the patient can break the blade without pain History & Physical

• Examine the TMs for hemotympanum or rupture • Test Cranial Nerves • Palpation • Tenderness • Step offs • Facial stability • Crepitus • Subcutaneous air • Cutaneous anesthesia History & Physical

• Eye Evaluation • Limited Visual acuity test • Pupillary response to light • Deformity or asymmetric appearance • Extra Ocular movements History & Physical

• Eye Injuries History & Physical

• Eye Injuries History & Physical

• Eye Injuries Penetrating Eye injuries

• Eye Injuries History & Physical

• Penetrating Injuries – Occult globe penetration – Eyelid lacerations • Nose – – Uncontrolled Epistaxis – Septal hematoma – CSF Rhinorrhea History & Physical

• – Subperichondral hematoma – Hemotympanum – Battle sign – Persistent Clear drainage

Management

 Tactical Field Care Management Control Hemorrhage Airway  Intubation • AVOID nasotracheal intubation • Consider Results of RSI • Be Prepared to quickly move to Surgical Airway Intervention • Face to Face intubations Management

• Hemorrhage Control – Direct Pressure – Avoid blind clamping and ligation – Nasal hemorrhage may require A&P packing – Continued severe bleeding may require surgical intervention to ligate associated major vessels or to reduce broken facial and control hemorrhage Management

• Airway Management Options – Awake intubation – Laryngeal Mask Airway – Fiberoptic Intubation/Glidescope – Percutaneous transtracheal jet ventilation • Temporizing adjunct. I usually carry a set up with me – Cricothyroidotomy

Maxillofacial Trauma-Specific Injuries • Nasal Fracture Maxillofacial Trauma-Specific Injuries Maxillofacial Trauma-Specific Injuries • Nasal Fracture – The nose is the most frequently injured facial structure, accounting for approximately 40% of bony injuries in facial trauma. – Packing the nose usually controls hemorrhage. – Evaluate for septal hematoma and CSF leakage. • Drainage of clear rhinorrhea immediately after trauma to the mid face and up to several days later should alert the clinician to the possibility of this associated fracture of the cribriform plate. Maxillofacial Trauma-Specific Injuries • Orbital Fracture – The thinnest and weakest area of the is the floor. Typically, the fracture occurs in the posteromedial region of the orbital floor – a “blow-out” fracture • The usual mechanism is a blow to the eye with the forces being transmitted by the soft tissues of the orbit downward through the thin floor of the orbit. The contents of the orbit (including fat, soft tissues, the inferior oblique muscle, or the ) can protrude through the fracture and become entrapped. Maxillofacial Trauma-Specific Injuries • Orbital Fracture Findings – Entrapment of the inferior oblique or the inferior rectus muscle can lead to restriction of orbital movements and resultant diplopia. The entrapment of both muscle and soft tissues can displace the globe posteriorly and inferiorly, adding to the diplopia and enophthalmos. The diplopia is most pronounced in upward gaze. Maxillofacial Trauma-Specific Injuries • Zygomatic Fracture – Because the zygoma is a thick , it is rare to have an isolated fracture of the zygoma. Most commonly, the fracture extends through adjacent bones which are often thinner. – Arch facture can impinge on the underlying temporalis muscle, resulting in trismus – Zygomaticomaxillary fractures are often associated with severe facial edema, so the true extent of the injury may be obscured. As with other fractures involving the orbit, diplopia may be reported by the patient

Nate Quary V/S Rivera Maxillofacial Trauma-Specific Injuries • Mandibular Fracture – The mandible is the tenth most commonly injured bone in the body and the second most commonly injured bone in the face.

Dos Anjos taps to Clay Guida UFC117 Maxillofacial Trauma-Specific Injuries

Body 30-40 % Angle 25-30 % Condyle 15-17 % Symphysis 7-15 % Ramus 3-9 % Alveolar 2-4 % Coronoid Process 1-2 % Maxillofacial Trauma-Specific Injuries – The most common cause of mandibular fractures is assault (50-75%). Injuries sustained in altercations are more often located in the mandibular angle region. – All fractures involving the dentoalveolar region are open fractures and require IV antibiotics. Often, a plate or a group of teeth are loose and blood may be found at the gingiva. Maxillofacial Trauma-Specific Injuries

The Le Fort I fracture is a horizontal fracture above the roots of the teeth and extends from the piriform sinus of the nose to the pterygomaxillary fissure, separating the maxillary tuberosity from the pterygoid plates. The mobile fragment of maxillary bone is often likened to a loose upper denture, containing the teeth and palate. The fracture results from a horizontal blow applied to the anterior and can be a single fragment or comminuted fragments. Maxillofacial Trauma-Specific Injuries The Le Fort II fracture courses upward through the infraorbital rim, through the medial orbit and the nasal bones. Since the fragment forms a triangular shape, this is often called a pyramidal fracture. Maxillofacial Trauma-Specific Injuries

The Le Fort III fracture crosses the maxilla, nasoethmoid complex, and the zygoma. This fracture is often termed a craniofacial dislocation or separation since the entire midface is now mobile. A complete bilateral Le Fort III fracture is rare and caused by massive trauma. Spinal fluid leakage is common. The remaining soft tissue attachments are often only the optic nerves, so gentle evaluation is appropriate Maxillofacial Trauma-Specific Injuries • Maxillary Fracture – A “simple” Le Fort fracture is actually uncommon for two reasons. First, rarely do fractures in the midface follow the suture lines describe by Le Fort. The fractures follow the path of least resistance and may be comminuted and multiple. – Secondly, blows to the face are often from an angle, so that a facial fracture may have a Le Fort II component on one side and a Le Fort III component on the other side.

Blast Injury

Pt suffered in close proximity to face. Pt. is alert and awake, but she is irritated and complains of pain with decreased vision in her right eye. She has no other associated injuries. Blast Injury

•Right upper eyelid is mildly edematous with a noticeable puncture . •Notably proptotic, and the sclera is injected with chemosis. •The patient has restricted movement of the affected eye. The pupil is round, 2 mm in diameter, and minimally reactive to light. •She has no light perception in that eye. •Instillation of fluorescein reveals no corneal damage. Acute Orbital

• Acute orbital compartment syndrome (AOCS): AOCS is an ophthalmologic emergency – Penetrating trauma or after recent retrobulbar anesthesia (eg, for facial surgery) with the formation of a retrobulbar hematoma – The hematoma increases the IOP, compromising blood flow from the ophthalmic artery and leading to compartment syndrome. In addition, the globe itself can be forced anteriorly into the orbital rim. – The medial and lateral canthal tendons tether the globe to the orbital rim and prevent the release of pressure, resulting in proptosis and, more importantly, a precipitous rise in IOP. – with vision loss unless the increased pressure is promptly relieved. Permanent ischemic complications may occur with as little as 2 hours of increased pressure. Lateral Canthotomy

• It is generally misconceived that a canthotomy alone is enough to decrease intraorbital pressure.

•The intraorbital pressure is not reduced until the inferior crux of the lateral canthus is resected and the lower eyelid released.

•The most important aspect of this procedure is that it can save the vision.

Auricular Hematoma

Georges St-Pierre GSP vs. Carlos Condit FIGHT VIDEO UFC 154 Nasal Septal Hematoma Ocular Trauma

• Eye Injuries Penetrating Eye injuries

• Eye Injuries Nose Packing Management

• Know When to Questions and Answers