Maxillofacial Trauma– Dr Anna Fang

  • Associated complications- airway compromise, hemorrhage, C spine injury, TBI, ocular injury, nerve injury
  • Orbital injuries
    • CANNOT MISS: ruptured globe, retrobulbar hematoma, entrapment
    • Exam: pupils, EOM, pressures, visual acuity, +/- fluorescein
      • Stretch of optic nerve can lead to oculo-cardiac reflex- brady, nausea, syncope
    • Orbital fractures
      • Fractures of the wall can lead to entrapment or hematoma
      • Limited EOM in the setting of trauma can be indicator of occult fracture
      • Isolated fracture with normal exam can be DC with close follow up
    • Ophtho consult: abnormal physical exam, entrapment, globe rupture, laceration
    • Typically should have a maxillofacial consult if available
  • Zygomatic injuries
    • Makes up the walls of the orbit and maxillary sinus
    • Exam: can appreciate depression inferiorly and laterally to the eye
    • Non-displaced fractures can be discharged with sinus precautions
    • Complex fractures need maxillofacial consult +/- ophtho
      • Antibiotics for open fractures (typically unasyn)
  • Nasal injuries
    • CANNOT MISS: nasal septal hematoma, CSF leak
    • Exam: be sure to inspect the inferior aspect of the nares
    • Closed fractures without swelling can be discharged with delayed follow-up
      • Early fracture reduction does not have better outcomes
    • Complicated fractures should be seen by ENT/max face
      • Look for external and internal lacerations
      • Open treated with antibiotics
    • Septal hematomas
      • Will have hematoma that forms along the septum of the nares
      • Drainage: topical lidocaine and vasoconstrictors, aspirate or incise with 15 blade, nasal packing after
  • Midface/Maxillary fractures
    • Made up of the maxilla, orbit, and the zygoma
    • Assess bite for all maxillary/mandibular fractures
    • Le Fort fractures associated with other injuries and high injury mechanism
      • Type 1: separation of the maxilla
      • Type 2: separation of the maxilla and nasal bone
      • Type 3: floating face involving the maxilla, orbit, zygoma, and nasal bone
        • High risk for surgical airway
      • Will all need maxillofacial consult
  • Mandibular injuries
    • Commonly fractures in two locations
    • Exam: tongue depressor test (bilateral), intraoral exam to look for lacerations
      • Intraoral lacerations > open fracture
    • Consult for open fractures and start antibiotics
    • Closed fractures can be discharged with outpatient follow up
      • Pressure dressing along the jaw/scalp to stabilize the jaw
  • Dental injuries
    • Urgent consult for avulsion, intrusion (>3mm), ellis 3 tooth fracture (fracture through the enamel, dentin, and pulp)
    • Where did the teeth go??? CXR or CT for evaluation
  • Management
    • In severe maxillofacial trauma there is a high likelihood of a need for a surgical airway
      • Can be very difficult to bag these patients, be cautious using nasal airway adjuncts, reassess frequently
    • Bleeding in facial trauma
      • Pack the bleeding cavities (oral and nasal), IR late for embolization
  • Exam considerations
    • Full facial nerve (motor and sensory), rock the hard palate, assess for bite, full ocular examination, evaluate inner ear and oral cavity
  • Social Determinants
    • Have a high suspicion for domestic violence as a potential etiology and NAT in children

Hemorrhage in Pediatric Trauma– Dr Chisom Nnadi

  • Leading reversible cause of death in pediatric patients
    • In massive hemorrhage hypoxia, acidosis, and hypothermia can lead to coagulopathy complicating resuscitation
  • After receiving 2-4u pRBC patients can have hypocalcemia due to chelation factors in blood
  • First stop the bleeding (pressure, proximal compression, hemostatic agents, elevation, splinting)
    • Hard signs of arterial bleed: expanding, pulsatile, thrill/bruit, loss of distal pulses
    • Indications for ED thoracotomy: presence of spontaneous circulation in the field OR hemodynamic instability in trauma AND presence of trauma/thoracic surgeon
      • Contraindications similar to adults (no signs of life, asystole, etc.)
  • Remember that pediatrics patients can compensate more than adults and will often present tachycardic when in shock but no hypotensive
  • Lab testing: type and screen, lactate, CBC, PT/INR, PTT, fibrinogen, electrolytes
  • Pediatric patients will become hypothermic more easily than adults, so may want to use rapid transfuser to warm
  • Volume of blood products
    • pRBC are 250-300cc/unit, whole blood is 450cc/unit
    • pRBC dosing 10cc/kg
    • At BMC no whole blood for patients under 50kg
      • Use uncrossmatched O-
  • TXA is recommended in pediatric patients
  • Goal is permissive hypotension

Chest Pain in Pregnancy– Dr Alexandra Van Besien

  • PE most common in the 3rd trimester, 4x higher risk after C-section
  • No validated criteria in pregnant patient for ruling out PE
    • Keep in mind there is not external validation for YEARS
    • Multiple recommendations against the use of DDimer to rule out PE in pregnancy (overall very poor sensitivity in retrospective analysis)
    • In evaluating these patients if there are LE symptoms you should start with a LE doppler
  • Currently at BMC VQ scans can be done from 9a-430p
    • STAT VQ scans will trigger the tech on call
  • CTPA vs VQ scan
    • CTPA has much higher radiation to the mother and is more sensitive for detecting PE
    • VQ with 10x more radiation to baby due to radionuclide tracer, cannot detect other high risk thoracic pathology, and will likely be abnormal in a patient with underlying lung pathology due to baseline vent/perfusion mismatch
  • There are no absolute contraindications for TPA in pregnancy
    • In the same vein, no contraindications for ECMO
  • Dissection, like in other patients, will present atypically
  • SCAD (spontaneous coronary artery dissection)
    • Leading cause of mI in pregnancy and postpartum period (majority 3rd trimester)
    • Standard of diagnosis is coronary CT or cath
    • Treat with antiplatelet, consider AC but not necessary
      • ASA is more safe in third trimester
      • DAPT can be given
      • Beta blockers are category B
    • No definitive management options, supportive care and medical management
  • Resources

Chest Pain, Pregnancy, and ECMO– Dr Alina Khurgel

Black History and Medicine– Dr Jaionn Griner

  • Brief timeline of significant events in black history
    • Juneteenth originated in June 19, 1865 after the emancipation of slaves in Galveston Texas by union troops
    • 1896- institution of separate but equal clause in case of Plessy v Ferguson
    • 1964- institution of the civil rights act prohibiting discrimination based on race, color, sex, religion, or nationality
    • 1966- formation of the black panthers in response to persistent racial inequality and over policing of blacks
      • In 1967 in response to police patrols a bill was introduced to repeal open carry of weapons which eventually passed
    • 2023- affirmative action deemed unconstitutional by supreme court
  • Dark history of medicine
    • Tuskegee syphilis study- 40 year study where 400 black men were provided free healthcare in exchange for observation of the disease progression of syphilis
      • Ultimately they were lied to about the diagnosis and not treated when the diagnosis was discovered
      • Participants expired and had many complications related to the disease
    • J. Marion Sims- developed various surgical techniques for OBGYN by operating on enslaved women WITHOUT anesthesia
    • During COVID19 pandemic there was a disproportionate amount of black patients who were both infected and died in comparison to white counterparts
  • How does this affect us?
    • Microaggressions– subtle intentional and unintentional interactions communicating bias towards underrepresented groups
      • Microassault- says something discriminatory but does not think their actions are harmful
      • Microinsult- unintentional comments said in a discriminatory way
      • Microinvalidation- actions and behaviors that deny racism and discrimination
    • Stereotype threat– the risk of confirming negative stereotypes about an individual’s identity leading to increased cognitive load
    • White supremacy culture– the ideas, beliefs, and actions of white people are superior to people of color
      • Reproduced by all institutions in our society to market a white image
  • Resources